Why the unspecified side code is used when a bilateral condition has no documented side

When the Chart Leaves It Open: Coding Bilateral Conditions Without a Specified Side

Here’s a scenario that trips up more than a few newcomers: a patient has a bilateral condition, but the medical record doesn’t say which side is affected. Do you code left? right? both? Or something else entirely? The short answer is simple, and it keeps records honest and data clean: use the unspecified side code.

Let me explain why this matters, and how to handle it with confidence.

What “laterality” means in ICD-10-CM (and why it matters)

ICD-10-CM keeps track of where a problem is on the body. That’s not just clerical detail; it affects treatment plans, reimbursement, and data quality. In many conditions, there are explicit codes for the left side, the right side, and often a bilateral form that means “both sides.” There are also codes that say “unspecified side.” If the chart clearly shows a bilateral condition, and the clinician notes both sides are involved, you’ll often use the bilateral code. If the chart says a patient has a condition that can affect either side but doesn’t specify which is involved, you have to be careful not to assume a side.

In practice, the choice isn’t random. It’s guided by the principle that the coding should reflect exactly what the record documents, without overreaching. When the record is silent about side, the most accurate representation is an unspecified side code. This choice preserves the bilateral nature of the problem while acknowledging the lack of side-specific information.

The key question and the right answer

Question: If a medical record does not specify the side for a bilateral condition, which code should be assigned?

A. Left side code

B. Right side code

C. Unspecified side code

D. Single condition code

Correct answer: Unspecified side code.

Why C is the right pick boils down to fidelity and timing. Using a left or right code would imply a side is known, which the chart does not confirm. On the other hand, a “single condition” code misses the bilateral nuance entirely. The unspecified-side option sits between those extremes. It communicates that the condition involves both sides in a bilateral sense but that the chart lacks the side-specific detail. That’s exactly the kind of precise, honest representation coding aims for.

A practical way to think about it

Imagine you’re labeling a storage box with “glasses” or “sunglasses.” If the box could contain either, and you don’t know which, you wouldn’t label it “left sunglasses” or “right sunglasses,” would you? You’d label it as “unspecified item” until you have more information. Medical coding works similarly. If the chart doesn’t tell you which side is affected, put the flag at “unspecified side” so the record stays accurate and useful.

Common pitfalls to avoid

• Guessing the side: It’s tempting to pick left or right when the chart is silent. Don’t. That would misrepresent the patient’s condition and could lead to billing and data integrity issues.

• Slapping a single-condition code on a bilateral problem: If a diagnosis can involve both sides, and the record hints at a bilateral issue, a solitary code strips away essential context. The unspecified-side option keeps the bilateral dimension intact.

• Ignoring laterality documentation entirely: If the chart later notes a side, you can adjust—coding is not a one-and-done task. But when the side remains unspecified, the safer route is to apply the unspecified-side code and document why you did so, in case of review.

How to handle when you’re unsure in real life

• Check the record thoroughly: Sometimes a clue is tucked away in a physical exam note, imaging report, or problem list. Look for phrases like “bilateral,” “both sides,” or “no side specified.” If you still don’t see a side, it’s a green light for unspecified-side coding.

• Seek clarification when possible: If you have access to the clinician or the chart’s other sections, a quick note asking which side is affected can save headaches down the line. A small clarification can prevent misinterpretation of laterality in the data.

• Document your reasoning: A brief coder’s note that explains “bilateral condition with no side documented” helps anyone who audits the case later. It’s not peeking into a chart; it’s ensuring the record remains transparent and usable.

• Be aware of the implications: While the unspecified-side code is appropriate, there are times when the documentation later reveals a side-specific finding. If new information appears, update the code accordingly. Codes are living data, not stone tablets.

Why this matters beyond the moment

• Data quality: Health systems rely on accurate statistics to study patterns, measure outcomes, and allocate resources. When side isn’t specified, using the unspecified-side code helps preserve the truth of the record while keeping the dataset clean enough to analyze properly.

• Clinical care continuity: If future clinicians review the chart, they’ll appreciate the honesty of the documentation. It helps them understand the patient’s history and plan treatment without making assumptions.

• Compliance and audits: Payers and auditors look for precise use of laterality. The unspecified option signals that you’re following guidelines, not guessing. That’s the sort of compliance behavior that reduces denials and promotes smooth reimbursement.

A tiny memory aid you can carry

• When in doubt about side for a bilateral condition, think: “Bilateral but unspecified.” If the chart doesn’t name a side, the code should name the lack of side information. It’s a simple rule, but it keeps the logic clean and the record honest.

A quick dialogue you might hear in a coding room

• Colleague: “This says bilateral, but there’s no side noted.”

• You: “Then we code as unspecified side. It captures the bilateral nature without assuming a side.”

• Colleague: “Makes sense. And if later it gets clarified?”

• You: “Update the code to reflect the new information. Records aren’t fossils; they should evolve with the facts.”

Bringing it all together

Coding isn’t about chasing a perfect answer every time. It’s about honoring what the chart really shows and using the codes that describe that truth without embellishment. When a bilateral condition lacks side documentation, the unspecified-side code is the thoughtful, standards-aligned choice. It acknowledges the bilateral nature of the diagnosis while staying faithful to the clinical detail the record provides.

If you’re new to this, you might feel a bit of friction—the urge to pin a side down, or to simplify for the sake of a tidy data set. That impulse is normal. The right approach, though, is a little more disciplined: preserve accuracy, seek clarification when possible, and document your reasoning. In the end, you’ll find that good coding doesn’t just meet rules; it tells a story the whole care team can trust.

A few closing thoughts to keep in your toolkit

• Always check the record first. If it’s silent on side, go with unspecified-side coding.

• When in doubt, ask and annotate. A short note can prevent questions later.

• Remember the bigger picture: accurate laterality improves patient care, supports meaningful data analysis, and helps keep the revenue cycle running smoothly.

If you enjoy exploring the practical edges of ICD-10-CM, you’ll notice a pattern: clarity beats cleverness every time. And in the world of medical coding, that clarity often lives in the quiet choice—the unspecified side code—when the chart doesn’t spell out a side.