What to do when no side is identified in ICD-10-CM coding

What to do when the side is a mystery in ICD-10-CM coding

Let me level with you: sometimes the chart doesn’t say left, right, or both. In those moments, the right move isn’t a guess. It’s to use the unspecified code. Sounds simple, but it’s a careful practice that keeps medical records honest and reimbursement fair. So, let’s unpack why this matters and how to handle it with confidence.

Why laterality even matters in ICD-10-CM

In ICD-10-CM, many conditions have a built-in idea of “sides.” Left knee, right elbow, both feet—the system likes specifics. When the documentation clearly identifies a side, you code that side. But what if the note is vague? If the clinician hasn’t documented left or right, you don’t infer. You assign an unspecified code that signals the information is not complete. This isn’t a throwaway code. It’s a precise way to reflect what’s actually known in the chart. It helps keep data honest, which matters for patient care, population health tracking, and accurate payment.

Unspecified codes: what they are and why we use them

Think of unspecified codes as the honest default. They show that a condition exists, but the provider didn’t specify a side. Here are a few reasons these codes exist and why they’re important:

• Documentation gaps exist in real life, and the coding system respects that reality. Not every note will spell out every detail, and that’s okay.

• They preserve the integrity of medical records. Rather than guessing, the unspecified code records what’s actually documented.

• They support appropriate reimbursement. Payers rely on precise documentation; when a side isn’t documented, an unspecified code communicates that limitation rather than forcing a potentially wrong left-right assignment.

• They prevent incorrect coding for bilateral or lateralized conditions. If the documentation doesn’t clearly indicate one side, selecting a side code could misrepresent the patient’s condition.

Let me explain with a simple example. Suppose a chart notes “fracture of the forearm” but doesn’t say which arm. If you force a left or right code, you risk coding a side that isn’t documented. The safer, more accurate choice is the unspecified version of that fracture. Later, if imaging or notes confirm a side, the chart can be updated and the code adjusted. That update path is exactly how clean records stay clean.

Guidance for when to use unspecified codes

Here’s the practical rule of thumb: if the documentation does not specify which side is affected, you assign the unspecified code. It’s not about skipping detail or trying to “complete” the record from your desk. It’s about fidelity to the source information.

• Bilateral conditions: If the record explicitly states “bilateral,” you handle it according to the bilateral coding options in ICD-10-CM. If it says “both sides” but doesn’t name a side, you may still need a bilateral code rather than an unspecified one—depending on the exact coding guidelines for that condition.

• Unclear documentation for a lateralized condition: Use the unspecified code for that condition’s entry.

• When laterality becomes clear later in the chart: Update the code if you receive more precise documentation. Accurate coding is a dynamic process, not a one-and-done decision.

These choices aren’t about “getting away with” anything. They’re about aligning with coding guidelines and the reality of clinical documentation.

Real-world implications: accuracy, audits, and reimbursement

Missing or ambiguous side information isn’t just a clerical hiccup. It can ripple through care decisions and billing. Unspecified codes help ensure that the medical record reflects what’s known, without guessing. That clarity supports:

• Better data quality for research and analytics. When side details are present, researchers can draw more precise conclusions about outcomes and trends.

• More trustworthy coding audits. Auditors look for consistency between notes and the codes assigned. Unspecified codes tell a clear story: the side wasn’t documented.

• Fair reimbursement. Payers assess whether the coding matches the documentation. If the side isn’t documented, an unspecified code is a transparent choice.

Of course, this can be frustrating in the moment. Nobody loves a chart full of “unspecified” labels. But keep in mind: it’s a signal to clinicians and auditors that there’s room for improvement in documentation, not a failure in coding.

Tips to improve documentation (and minimize unspecified codes)

If you’re curious about how to reduce the use of unspecified codes, here are practical moves you can advocate for in your practice or learning journey:

• Encourage precise note-taking. When clinicians describe the condition, they should include side and context if relevant (e.g., left knee pain after a fall, right hand symptoms after a car accident).

• Use standardized prompts in the chart. Checklists or structured question sets help clinicians capture laterality consistently.

• Pair codes with the most specific documentation available. If a side is known, link it directly to the exact ICD-10-CM code. If not, the unspecified version is the best option.

• Leverage imaging and test results. Radiology reports, nerve studies, and other diagnostics often reveal side details that can unlock more precise coding.

• Conduct quick chart audits. A gentle, recurring audit can catch patterns—like repeated unspecified codes for conditions where sides are usually known—and guide targeted education.

A few real-world scenarios (and how to think about them)

• Scenario 1: A patient has a fracture noted in the forearm but no side is stated. The coder should select the unspecified forearm fracture code. If later the chart shows “left forearm fracture,” the code can be updated.

• Scenario 2: A patient has a bilateral carpal tunnel syndrome diagnosed, and the chart says “bilateral carpal tunnel.” Use the bilateral code or the appropriate separate codes as dictated by the guidelines.

• Scenario 3: A patient has pneumonia documented without a specified lobe involvement or side. The unspecified pneumonia code would be appropriate until more detail appears.

Keeping the rhythm: writing that feels natural but stays precise

As you write or review ICD-10-CM codes, mix clarity with a touch of conversational ease. You want a flow that’s easy to read, even when the topic is technical. Short sentences paired with a few longer ones help. A well-placed digression or analogy can anchor a point without derailing the main thread. And yes, a dash here and there can soften a dense idea and keep the reader engaged.

A quick analogy: think of codes as labels for a pantry. If you know the exact jar on the shelf, you label it precisely. If you’re not sure which jar it is, you label it “unspecified” and keep the rest of the pantry organized so you can update the label once you discover more details. The goal is not chaos; it’s honest cataloging.

The bottom line

When a side isn’t identified in the documentation, the right choice is an unspecified code. It’s a precise acknowledgment of what is known and what remains unclear. This approach upholds the integrity of the medical record, supports fair reimbursement, and leaves room to refine the entry as more information becomes available.

If you’re working through ICD-10-CM coding topics, remember this: unspecified codes aren’t a handicap. They’re a careful tool—one that helps ensure reports reflect reality, guidelines are respected, and patient care remains front and center. And as you continue learning, you’ll find that good coding isn’t about clever guessing. It’s about clear communication, accurate documentation, and a steady commitment to accuracy in every chart you touch.