2017 General Coding Guidelines

2017 ICD-10-CM guidelines - General coding guidelines:

Laterality:

Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side.

When a patient has a bilateral condition and each side is treated during separate encounters, assign the "bilateral" code (as the condition still exists on both sides), including for the encounter to treat the first side.

For the second encounter for treatment after one side has previously been treated and the condition no longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists (e.g., cataract surgery performed on each eye in separate encounters). The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition in the previously-treated site. If the treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate.

BMI, Ulcer Depth/Stage, Coma Scale, NIHSS:

BMI, non-pressure chronic ulcer depth, pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) code assignment may be based on medical record documentation from clinicians who are not the patient’s provider… (e.g., a dietitian often documents the BMI, a nurse often documents the pressure ulcer stages, and an emergency medical technician often documents the coma scale).

The associated diagnosis (such as overweight, obesity, acute stroke, or pressure ulcer) must be documented by the patient’s provider.

The BMI, coma scale, and NIHSS codes should only be reported as secondary diagnoses.

Documentation of Complications of Care:

Complication code assignment is based on the provider’s documentation unless otherwise instructed by the classification.

The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.