News: Laterality among 2017 updates to ICD-10-CM guideline general conventions

The Cooperating Parties made revisions to the 2017 ICD-10-CM Official Guidelines for Coding and Reporting to explain how bilateral conditions should be reported when the two sides are treated during separate encounters, as well as what codes would be appropriate once one side has been treated. The easiest way to explain how this works is to show an example of the new guidelines. Consider the following:

Patient has bilateral age-related nuclear cataracts that necessitate surgical repair. The patient will undergo two surgeries during separate encounters—one for each eye— to allow time in between for complete healing of the first eye.

For the first encounter to treat the right eye (i.e., first side), use a bilateral diagnosis code for the cataracts (H25.13 [age-related nuclear cataract, bilateral]) because the patient still has cataracts in both the right and left eyes.

For the second encounter to treat the left eye (i.e., second side), use the unilateral code for the left eye cataract because the right eye no longer has a cataract. However, a cataract extraction status code may be reported to identify the right eye has already been treated. Coders should report:  

• Diagnosis: Age-related nuclear cataract, left eye (H25.12)
• Cataract extraction status, right eye (Z98.41)
  
  • Please see the instructional note stating “If an intraocular lens implant was placed in right eye, use additional code Z96.1.”

The exception to the reporting above would be if the treatment on the first side did not completely resolve the condition. In that case, the bilateral code would still be appropriate.

Another practical example of when this guideline could apply is with patients with severe degenerative joint disease of both knees, requiring bilateral total knee replacements performed during separate encounters.

Editor’s Note: This article was written by Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS, and was originally published in JustCoding. McCall is the director of HIM and coding for HCPro, a division of BLR, in Danvers, Massachusetts. For more information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com.