Knowledge Base Article

Q:

If a patient is admitted and documented with a condition in which laterality can be distinguished such as bilateral osteoarthritis of the knees, and only one side is being treated, would you report a diagnosis code only for the side receiving treatment?

A:

No.
You would assign the “bilateral” code.

• When a patient has a bilateral condition and the condition still exists on both sides, then a bilateral code is reported.
• Once one side has been treated and that condition no longer exists on that particular side then the appropriate “unilateral” code would be assigned.
• If treatment does not completely resolve the condition for the first side treated, then the “bilateral” code would continue to be reported.

Example #1: Patient is documented with bilateral osteoarthritis of the knees (stage IV of the right and stage III of the left) and is admitted for total knee replacement of the right knee.

ICD-10-CM code assignment would be:

M17.0 for Bilateral Primary OA of Knee

Example #2: H&P states patient with history of bilateral senile nuclear sclerosis cataract. Patient had great success with cataract surgery for the left eye 3 months prior and is now admitted for surgery on the right eye.

ICD-10-CM code assignment would be:

H25.11 for Age-related Nuclear Cataract, Right Eye

Example #3: Documentation shows patient with history of bilateral osteoarthritis of the hip. Total hip arthroplasty was performed on the left side 9 months prior successfully eliminating all pain and symptoms on that side. Patient is admitted now with continued pain on the right side which has been interfering with her daily activities.

ICD-10-CM codes assigned would be:

M16.11 for Unilateral Primary OA, Right Hip and
Z96.642 for Presence of Left Artificial Hip Joint