Bilateral Diagnoses

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August 13, 2015

Question:

I understand there are more diagnosis codes for bilateral procedures in ICD-10-CM. This makes sense and I get it. But I noticed that there are some diagnosis codes that don’t have a “bilateral” option. What should we do?

Answer:

Good question! And we agree that having some diagnosis codes that reflect laterality is a good idea. Some of the ICD-10-CM cerebrovascular diagnosis codes have right, left and bilateral options. However, some don’t have a bilateral option. The same is true for carpal tunnel syndrome – there are right and left diagnosis codes but not a bilateral code. So how should you code if a diagnosis is bilateral and a bilateral code does not exist? You’ll use both the right and left diagnosis codes in those cases. We cover this issue and many more in our two neurosurgery-specific ICD-10-CM webinars that you can find here: