If no bilateral code is provided and the condition is bilateral, how should the encounter be coded?

When coding for bilateral conditions, if a bilateral code is not provided, the correct approach is to use separate codes for the left and right side of the condition. This is important because accurate coding promotes clear communication about the patient's health status and ensures proper reimbursement for services.

Using separate codes allows for a detailed representation of the patient’s condition, which is crucial in clinical documentation. It ensures that healthcare providers can differentiate between the two sides, aiding in both treatment planning and follow-up care. Additionally, this approach aligns with coding conventions that encourage specificity in capturing the clinical picture.

In this scenario, using the code for unspecified side or documenting it for later coding does not provide the necessary specificity. Assigning a single code for bilateral may also not convey the true clinical scenario if both sides are involved but require distinct coding. Therefore, coding each side separately ensures clarity and accuracy in the medical record.