ICD-CM Coding

Urgent Care: Bilateral ICD-CM Coding

Urgent care often addresses common issues like joint or bone pain, which require careful consideration of ICD-CM 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 coding codes.

For musculoskeletal and connective tissue ICD-CM coding, some codes 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 ICD-CM 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.

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Michelle Anderson

Michelle Anderson brings 20 years of experience to her role as Implementation Manager at CodeEMR, where she provides education, training and compliance guidance to maximize value in each healthcare setting. She is an expert in medical coding and compliance, coding management, regulatory compliance, and healthcare operations, specializing in Federally Qualified Health Centers (FQHCs) and Community Health Centers. She holds multiple certifications, including AAPC Certified Professional Coder (CPC), Certified AI Medical Coder, Certified Risk Adjustment Coder (CRC), Certified Professional Medical Auditor (CPMA), Certified Medical Compliance Officer (CMCO), and Community Health (FQHC) Coding & Billing Specialist (CH-CBS). Michelle received her Associates of Science Degree from the Rhode Island Community College.