In coding, if no side is identified, what should you assign?

When coding in the ICD-10-CM system, if no side is identified for a condition, the appropriate action is to assign an unspecified code. Unspecified codes are used in situations where the documentation does not provide sufficient detail regarding the specific aspects of a condition, including laterality.

Unspecified codes serve several purposes: they allow for accurate reporting of diagnoses when complete information is lacking, and they help ensure that the records reflect the available clinical data without making assumptions. This is particularly important in maintaining the integrity of medical records and ensuring appropriate reimbursement for healthcare services.

In the context of bilateral conditions or any lateralized diagnosis, using unspecified codes avoids inaccurately assigning either a left or right code when the documentation does not clearly specify one side. This promotes coding accuracy and compliance with coding guidelines, which are essential for effective healthcare delivery and reporting.