ED Coding and Reimbursement Alert

Question: In your last issue (Vol. 20, no. 6), you advised ICD-10 codes for a tick bite in the thigh and ankle strain, and your advice directed the reader to codes that didn’t include laterality (left side or right side). Instead, you advised reporting a code for unspecified thigh and another for unspecified ankle. Can you suggest when this is the correct route versus reporting the appropriate anatomic site?

Codify Subscriber

Answer: If you have documentation of the anatomic site, then you absolutely should select the ICD-10 code that describes the left or right ankle or the left/right thigh. In cases when readers send questions to Emergency Department Coding Alert, the questions often don’t specify which body site is affected, so our advice typically suggests the diagnosis code for the unspecified body site rather than using the lateral code. However, in practice, you should always look further into the documentation for the affected site.

Example: In last month’s reader question, “Differentiate Splinting From Strapping,” we suggested reporting S96.919A (Strain of unspecified muscle and tendon at ankle and foot level, unspecified foot, initial encounter) since the question simply referred to a “sprained ankle.” However, in clinical practice, you should question the physician to determine whichankle was affected. Once you have that information, you’ll report the more specific code, such as S96.911A (Strain of unspecified muscle and tendon at ankle and foot level, right foot, initial encounter) or S96.912A (Strain of unspecified muscle and tendon at ankle and foot level, left foot, initial encounter).

In some cases, you’ll find that the patient’s condition was bilateral, and in these cases, you’ll report the ICD-10 code for the bilateral condition. “Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral,” the ICD-10-CM Official Guidelines for Coding and Reporting for 2017 indicate. “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.”