Wiki Unspecified Laterality - WHY????

[srandolph11]

If this has been answered before, please direct me to that thread.

Why do we have unspecified laterality codes? It does not make any sense to me. I cannot think of a scenario where this is needed. If someone has a great explanation of this I would love to hear it.

The EMR/EHR we used makes this the first possible selection when searching for codes and it causes so much havoc with the billing department.

I just want some clarity on this.

 

[LisaAlonso23]

Sometimes providers don't document laterality. I see it every once in a while but not too often.

 

[CBLENNIE]

Why do we have unspecified laterality codes? It does not make any sense to me. I cannot think of a scenario where this is needed. If someone has a great explanation of this I would love to hear it.

The EMR/EHR we used makes this the first possible selection when searching for codes and it causes so much havoc with the billing department.

I just want some clarity on this.

I 100% agree with you that there shouldn't be a scenario where the unspecified laterality codes are necessary, yes as @LisaAlonso23 stated sometime providers don't document it, but IMO then a query needs to be sent to the provider for clarification and updating of the record to specify the laterality.

To me the fact that the unspecified codes exist, procedure and diagnosis, just allows the providers get away with incomplete documentation in the medical record. Until we take away their ability to not specify the laterality of a code there are going to be providers who don't bother to fully document the procedure or condition in the medical record.

However, I can't picture a future where we don't have these unspecified codes because the push back from the provider community if there was an attempt to delete the unspecified codes would be big enough that that the decision makers will just give in.

Sorry for the mini rant, but I work on the insurance side of the industry having been in customer service, claims processing, auditing and payment integrity positions and the existence of these codes just frosts my cookies. It makes it harder on us to be confident that claims are being paid correctly when laterality impacts the processing of a claim.

I don't think there is any clarity to be had on the existence of these codes for the reasons I stated above. They exist, therefore they are used...

 

[TThivierge]

Hi SRandolph11,
Using unspecific laterality is a way for insurance companies to hardly pay or deny the claim. Does the provider list anywhere in notes which side it may be? If not use unspecified laterality dx and the loss of revenue is their fault not yours. As medical coder you cannot guess and it has to be documented. I have heard some say if it says unspecified laterality it is bilateral. Nope that data is not good enough for any medical coder.
Lady T

 

[amroach68]

I 100% agree with you that there shouldn't be a scenario where the unspecified laterality codes are necessary, yes as @LisaAlonso23 stated sometime providers don't document it, but IMO then a query needs to be sent to the provider for clarification and updating of the record to specify the laterality.

To me the fact that the unspecified codes exist, procedure and diagnosis, just allows the providers get away with incomplete documentation in the medical record. Until we take away their ability to not specify the laterality of a code there are going to be providers who don't bother to fully document the procedure or condition in the medical record.

However, I can't picture a future where we don't have these unspecified codes because the push back from the provider community if there was an attempt to delete the unspecified codes would be big enough that that the decision makers will just give in.

Sorry for the mini rant, but I work on the insurance side of the industry having been in customer service, claims processing, auditing and payment integrity positions and the existence of these codes just frosts my cookies. It makes it harder on us to be confident that claims are being paid correctly when laterality impacts the processing of a claim.

I don't think there is any clarity to be had on the existence of these codes for the reasons I stated above. They exist, therefore they are used...

Sometimes the provider documents unspecified if it's coming from another provider's previous documentation and their notes were sloppy --- or it's coming from the patient as their own historian. Doctors cannot lie and say there is a laterality if they honestly don't know. Think, patient with early dementia coming in for an AWV and they claim wrist pain. Which wrist? The patient "forgets" or isn't sure. Codes have to cover any possible scenario as weird or unfair as they may seem on the surface.

 

[CBLENNIE]

Sometimes the provider documents unspecified if it's coming from another provider's previous documentation and their notes were sloppy --- or it's coming from the patient as their own historian. Doctors cannot lie and say there is a laterality if they honestly don't know. Think, patient with early dementia coming in for an AWV and they claim wrist pain. Which wrist? The patient "forgets" or isn't sure. Codes have to cover any possible scenario as weird or unfair as they may seem on the surface.

Those are fair points and great examples. However, there are far too many claims that come into the insurance company with the laterality as unspecified and we don't deny claims for failing to bill to the highest level of specificity. So, our providers have no reason to make more of an effort to document and submit the laterality.

 

[whatwouldyousay]

It’s really frustrating to witness how many Radiology claims are denied for this reason but the Rads are mostly at the mercy of the referring physicians and the hospitals and information provided on orders is often lacking specificity. For example a PET Scan ordered for “Lung Cancer”. Those are expensive tests we end up making contractual adjustments for, over and over. I bet that the referring doc used a more specific code on their office visit claim though.

 

[TThivierge]

It’s really frustrating to witness how many Radiology claims are denied for this reason but the Rads are mostly at the mercy of the referring physicians and the hospitals and information provided on orders is often lacking specificity. For example a PET Scan ordered for “Lung Cancer”. Those are expensive tests we end up making contractual adjustments for, over and over. I bet that the referring doc used a more specific code on their office visit claim though.

Hi Whatwouldyou,
Go to Healthcare Business AAPC journal issue March 2023 there is an article there on radiological coding. It may help you.
Lady T