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bilateral diagnosis coding

Renee Posted Fri 11th of September, 2015 08:57:38 AM

we have a question about using the bilateral diagnosis codes in icd10 ~ our example - patient presents to this ortho specialty office and is diagnosed with bilateral primary hip OA. the patient/doctor deem that the lt is worse that the rt and the following visits focus on the lt hip and a total joint replacement surgery is done on the lt hip. should that diagnosis code be broken out into lt/rt from the beginning visit? or would it be coded out as bilateral until the point of surgery? thank you for your input.

SuperCoder Answered Mon 14th of September, 2015 02:05:20 AM

Use ICD-10-CM code for bilateral Hip OA till the point of surgery and then use the appropriate ICD-10-CM code for right Hip OA and Left hip after care.

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