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

When coding for a bilateral condition where the medical record does not specify which side is affected, the appropriate action is to use a code that indicates the unspecified side. This choice is aligned with the guidelines of ICD-10-CM, which aim to maintain accurate and effective medical coding practices.

Using an unspecified side code is essential because it acknowledges the bilateral nature of the condition while also reflecting the lack of specific clinical information provided. This ensures that a coder complies with coding standards and accurately represents the patient's diagnosis in a way that considers both the medical necessity and the coding framework.

In scenarios where only one side can be chosen, codes for left or right would misrepresent the clinical information by implying an affected side when it hasn't been documented. Additionally, selecting a single condition code would not convey the bilateral aspect of the diagnosis, potentially leading to incorrect data and analysis of patient conditions. Therefore, employing the unspecified side code preserves the integrity of the medical record and adheres to proper coding protocols.