SPOTLIGHT ON ICD-10-CM CODING ASSIGNMENTS FOR LATERALITY IN 2017

As anticipated, significant updates were made to the ICD-10-CM Coding Guidelines for 2017. These guidelines are a set of rules developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. These guidelines are located in the front of the 2017 ICD-10-CM Coding book. Be sure to take a look at the date at the beginning of the guidelines, if it doesn’t state “FY 2017” then download the current version at 2017 ICD-10-CM Official Guidelines for Coding and Reporting

Even though numerous updates took place, this article was written to focus on the new added guidelines for laterality.

THE BASICS – HOW THE GUIDELINES ARE ORGANIZED

Guidelines are organized into four sections:

• Section I Structure and conventions of the classification and general guidelines
• Section II Selection of principal diagnosis
• Section III Reporting additional diagnoses in non-outpatient settings
• Section IV Outpatient coding and reporting

PROVIDERS – THE SECTIONS THAT APPLY TO YOU 

Even though it has always been the case, the new 2017 guidelines stipulates, Guidelines in Section 1, Conventions, general coding guidelines and chapter-specific guidelines, should also be applied for outpatient services and office visits. 

In summary, guidelines in both sections (IV. and I.) have to be followed.

NEW GUIDELINES FROM SECTION I ON LATERALITY 

B. General Coding Guidelines, 13. Laterality (second paragraph):

When a patient has a bilateral condition and each side is treated during separate encounters, assign the “bilateral” code (as the condition still exists on both sides), including for the encounter to treat the first side. For the second encounter for treatment after one side has previously been treated and the condition no longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists (e.g., cataract surgery performed on each eye in separate encounters). The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition in the previously-treated site. If the treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate.

EXAMPLE: 

• First encounter: On December 1 st the patient comes into the office. Patient is diagnosed with varicose veins in both lower extremities with swelling.

I83.893 Varicose veins of bilateral lower extremities with other complications

• Second encounter: Patient returns on December 5th to have the right lower extremity treated.

I83.893 Varicose veins of bilateral lower extremities with other complications Explanation: Even though only the right side was treated, because the condition on the left side still exists, the bilateral code is assigned.

• Third encounter: Then on December 12th the left lower extremity is treated (condition on the right side no longer exists)

I83.892 Varicose veins of left lower extremity with other complications

• Explanation: Because there was successful treatment on the right side (condition no longer exists) assign the left (unilateral) code for the side where the condition still exists.

SUMMARY

1. ICD-10-CM Official Guidelines for Coding and Reporting are located in the front of the ICD-10- CM Code Book. For your professional services, you need to follow:

• Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services
• Section I. Conventions, general coding guidelines and chapter specific guidelines

2. Yearly review these guidelines as new information and revisions take place

3. Specific instructions for laterality:

• When a patient has a bilateral condition and each side is treated during separate encounters, assign the “bilateral” code, including for the encounter to treat the first side. For the second encounter for treatment after one side has previously been treated and the condition no longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists. The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition in the previously-treated site. If the treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate.