Bilateral Diagnosis

Messages
2
Best answers
0
If a patient is diagnosed with a Bilateral diagnosis. Do you count as 1 or 2 problems? For example bilateral hearing loss. What if the treatment is different for each ear?
 

TheStephCode

Networker
Messages
62
Best answers
0
Interesting question and I will be curious to see how others respond. If it is one diagnosis of one body area,... b/l breast cancer or b/l knee arthritis for example, I count it as one. However, I've never really paused to consider the possibility that it may be more than one due to laterality so again, I'm very curious to see how others handle it.
 
Last edited:
Messages
812
Best answers
0
In my opinion, it should be counted as two for several reasons. Although the diagnosis is the same, it's two different anatomical sites (left ear/right ear, left breast/right breast). Even if it's the same BA, think about coding for procedures. Certain modifiers exist so that payment can be made for the same procedure on separate sides. The condition may currently exist on each side, but one side may be worse than the other, one may improve or be cured, and so on. Treatment could be given to only one side in a particular visit. A great example of this is cataracts. Also, one of the main improvements with the I-10 is the ability to code so specifically, including laterality. Then you should also consider CPT codes. Some don't allow 50 mods or LT/RT because the side is specified within the code description. In order to append the appropriate DX to such a code, you would need to view them separately. Better yet, think about if a person breaks both of their arms in the exact same place in the exact same way. It's the same general idea; they're both broken, in the same location, in exactly the same way, but that would never be coded as one diagnosis, if that makes sense. Ultimately, it's just by chance that a condition may exist on both the left and right side.
 
Messages
112
Location
Chennai
Best answers
0
If a patient is diagnosed with a Bilateral diagnosis. Do you count as 1 or 2 problems? For example bilateral hearing loss. What if the treatment is different for each ear?
For a bilateral diagnosis if there is a code specific for bilateral, code it; if not, code both diagnosis. Even if the treatment is different for both side(for different treatment you code cpt code with modifier for laterality).
eg: H91.93 for hearing loss bilateral even if both ear has different treatment(diagnosis same)
 
Last edited:
Messages
812
Best answers
0
I stand by my original statement that it would be two. If the problem is new to the provider, just happens to be bilateral, and the provider orders further tests on ONE side but not the other, how would you calculate the MDM for an E/M?
New problem to provider with no additional work up planned vs New problem to provider with additional work up planned.
It may be one diagnosis, but it's two problems. The problems co-exist, but that doesn't mean they are dependent on one another. Not to mention the fact that the provider had to examine each side to make or evaluate the diagnosis.

I think the issue here is the use of the words "problem" and "diagnosis" interchangeably. They are not necessarily the same thing, especially if you're working on E/M billing. Maybe this will make more sense:

diagnosis
1. determination of the nature of a cause of a disease.
2. a concise technical description of the cause, nature, or manifestations of a condition, situation, or problem.

The problem is used to create the diagnosis, therefore they can't be the same thing.
 
Top