January 20, 2011 | | Comments 2
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ICD-10-CM codes can tell a different side of the diagnosis story

As many may be aware, laterality has been added in ICD-10-CM to increase specificity. Codes assigned for conditions such as fractures, burns, and pressure ulcers will indicate right side versus left side. Don’t panic—there are still codes available for unspecified “sides.”

For example, consider the following ICD-10-CM categories:

  • L89.60 (pressure ulcer, unspecified heel)
  • L89.61 (pressure ulcer, right heel)
  • L89.62 (pressure ulcer, left heel)

Note that this series of codes also requires a sixth digit to identify the stage of the pressure ulcer (i.e., stage I-IV or unstageable).

Another example illustrating laterality is the ICD-10-CM code for a fracture of the shaft of the radius (ICD-10-CM category S52.3)

The fourth digit identifies the type of fracture (e.g., greenstick or transverse), and the fifth and sixth digits identify right versus left and in some cases whether the fracture was considered displaced or nondisplaced. The final character identifies if it was initial, subsequent, or sequela.

The fracture example brings to mind something for which I am not sure I have seen the answer. Because ICD-10-CM codes will be used for professional and outpatient services and yet the HCPCS codes (CPT and HCPCS II) will still be used to report the procedures, will it still be necessary to report the –RT or –LT modifiers?

I would presume so because identifying whether a physician performed a procedure on the right or left is important. But would it be redundant, like putting a -50 modifier (bilateral procedure) on a procedure code that states bilateral in the description?

It could possibly cause issues if the diagnosis is somehow coded as a fracture of the right shaft of the radius, but for some reason the CPT procedure is assigned with modifier-LT. I could envision the potential of medical necessity denials that we do not encounter using ICD-9-CM diagnosis codes.

For example, we currently have ICD-9-CM diagnosis codes that indicate bilateral hernias. Yet the CPT Manual still instructs coders to utilize modifier-50 when hernias are repaired bilaterally. This reference leads me to believe that even though ICD-10-CM codes will have the added specificity of laterality, coders will still use modifiers –RT, -LT and -50 (for that matter) as they currently do.

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Filed Under: Coding


Shannon McCall About the Author: Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, is director of coding and HIM at HCPro, Inc. Shannon serves as the director over the Certified Coder Boot Camp ® programs. She developed the Certified Coder Boot Camp® – Inpatient Version, the Evaluation and Management Boot Camp and most recently the ICD-10 Basics Boot Camp®. As a member of HCPro, Inc.’s Revenue Cycle Institute, Shannon works with hospitals, medical practices and other healthcare providers on a wide range of coding-related issues with a particular focus on education. Shannon has extensive experience with coding for both physician and hospital services. Prior to joining HCPro, she worked for a national medical practice management company, where her duties included serving as a client manager and as an instructor for the in-house coding training. Shannon also previously worked for a national consulting firm focusing on hospital inpatient, outpatient and ER services. Shannon is accredited as a Registered Health Information Administrator and a Certified Coding Specialist and a Certified Coding Specialist – Physician and an ICD-10-CM certified trainer by the American Health Information Management Association. She is also accredited as a Certified Professional Coder and a Certified Evaluation and Management Coder and is considered an approved instructor of the Professional Medical Coding Curriculum by the American Academy of Professional Coders. She is certified as a Certified Clinical Documentation Specialist and also actively serves as an advisory board member of the Association of Clinical Documentation Improvement Specialists (ACDIS). She served as the 2008-2009 Elected Director of the Virginia Health Information Management Association. Shannon holds a Bachelor of Science in Health Information Administration degree from the Medical University of South Carolina.

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  1. If the MD does not document laterality then can the coder use the wound care or nursing documentation to code the laterality or is it that the coder can only obtain that specificity from MD documentation?

  2. What is the proper coding for bilateral hip pain:
    M25.51 and M25.52



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