If there is no code for bilateral glaucoma but the type and stage are documented, how should it be coded?

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When coding for conditions like bilateral glaucoma, it is essential to represent the specified type and stage accurately. If there is no specific code available for bilateral glaucoma but the documentation includes the type and stage, using one code for the type along with the appropriate stage character is appropriate. This approach aligns with coding guidelines that prioritize specificity when a bilateral code is not available.

Using just one code effectively communicates the patient's condition while incorporating the relevant stage, which can be crucial for treatment and management considerations. It ensures that the record reflects the clinical picture without overcomplicating the coding scenario where bilateral coding is not possible. This method is efficient and aligns with the general principles of coding accuracy and simplicity.

The other options may lead to confusion or misrepresentation of the documented condition. Reporting codes for each eye or utilizing both bilateral and single eye codes could imply that there are separate conditions for each eye rather than a single bilateral condition represented through the type stage code.

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