Urgent Care: Bilateral ICD-CM Coding

Urgent care often addresses common issues like joint or bone pain, which require careful consideration of medical coding guidelines. It’s crucial to ensure that healthcare providers are familiar with these guidelines and that EHR systems offer the full descriptions of ICD-CM codes.

For musculoskeletal and connective tissue ICD-CM codes, some include options for left side, right side, and bilateral diagnoses, while others lack bilateral options. In cases where bilateral diagnosis codes are unavailable, providers must code for both sides separately.

Providers need to determine all relevant diagnoses, particularly when conditions are bilateral, yet some EHR systems may provide limited code descriptions, potentially leading to incomplete coding.

For instance, if a patient experiences pain in bilateral shoulders, two distinct ICD-CM codes are necessary:

  • 511: Pain in the right shoulder
  • 512: Pain in the left shoulder

If a provider only codes for one shoulder due to limited EHR descriptions (pain in shoulder), and subsequently orders an X-ray for both shoulders, insurance may deny one X-ray due to mismatched coding.

For example:

  • 73020-RT: M25.511 (pain in right shoulder)
  • 73020-LT: M25.511 (pain in right shoulder) – denied because it should have been coded as M25.512.

Key considerations include ensuring providers understand the requirement to code for both right and left sides in cases of bilateral pain and confirming that EHR descriptions include necessary details for accurate selection of ICD-CM codes.