If no bilateral code is provided for a bilateral condition, what should be done?

In the context of coding for bilateral conditions, the appropriate approach when no bilateral code is provided is to assign separate codes for each side affected by the condition. This practice aligns with the ICD-10-CM coding guidelines, which require specificity in coding to ensure that both sides of the body are accurately represented in the patient's medical record.

By assigning separate codes for each side, coders ensure that the entire clinical picture is captured, which is essential for proper tracking, treatment planning, and reimbursement. This method also helps to avoid ambiguity in documentation, allowing healthcare providers to clearly communicate the details of the patient's condition.

In cases where a bilateral code is available, it would be used instead; however, when it is absent, the best approach is to code for each side distinctly. This not only maintains the accuracy of the coding but also reflects the nuances of the patient's condition more effectively.