CodingQuestion 26 of 100
When laterality applies to an ICD-10-CM code, the coder must specify:
a.The severity of the pain only
b.The provider's specialty
c.Whether the condition affects the right, left, or is bilateral
d.The date of the injury
Explanation
Many ICD-10-CM codes require documentation of laterality, identifying the right side, left side, or bilateral involvement of a paired body part. When the record does not state the side, an 'unspecified' code may be the only option, but this reduces specificity. Coders should query the provider when laterality is clinically relevant but missing.
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