Documentation and Coding of Laterality and Specificity

Hear Joan L. Usher, BS, RHIA, ACE, a nationally recognized expert in Home Health Coding, discuss Documentation and Coding of Laterality and Specificity in this free, brief presentation.


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About the Author

Joan Usher, BS, RHIA, HCS-D, ACE
Joan is President of JLU Health Record Systems, a leader in Health Information Management and coding solutions. A nationally recognized expert in the field of health information management, Joan has taught coding for over 25 years and has educated over 20,000 people nationwide. She is author of the JLU Rapid Reference Coding Guide, an easy-to-use coding guide in ICD-10 for common home health diagnoses, and author or editor of numerous courses, books and articles on coding, reimbursement methods, clinical documentation improvement, and health record requirements.

5 thoughts on “Documentation and Coding of Laterality and Specificity

  1. Kimberly Nimmer - May 29, 2018 at 11:49 pm

    To clarify regarding the capability of using nurses notes to further define diagnosis coding to the highest specificity (eg: ulcer scenario), only those diagnoses listed in the coding clinic are able to be obtained from the nonprovider documentation, correct? In the event of other diagnoses where the nonprovider documentation indicates higher specificity than the providers documentation, the provider would need to state the nurses notes were reviewed and agreed with, for the coder to assign the higher specific ICD10 code, correct?

    • Libman Education - June 4, 2018 at 3:22 pm

      Kim, thank you for listening to the Libman Education webinar on Documentation and Coding of Laterality and Specificity. As Joan stated in her webinar only those conditions specifically mentioned in the guidelines (BMI, depth of non-pressure ulcers, pressure ulcer stages, coma scale, and NIH stroke scale) may be further specified for code assignment based on medical record documentation from clinicians who are not the patient’s provider. The associated diagnosis (such as overweight, obesity, acute stroke, or pressure ulcer) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification.

      This guideline does not apply to other conditions where laterality and specificity are lacking. When in doubt about specificity, and it is important to the case, the best practice is to query the provider for the information. Throughout the guidelines coders are encouraged to query the providers when the documentation is unclear.

      We hope you continue to enjoy learning with Libman. — Sandy Macica

  2. Patti Bova - May 30, 2018 at 5:12 pm

    Would lv to watch your presentstions

    • Libman Education - June 1, 2018 at 12:38 am

      Thanks Patti! Please stay tuned — we have more videos from Joan planned for the future. — Libman Education

  3. Edith R Drebot - May 30, 2018 at 11:40 pm

    Thank you for a very interesting program review. I am an outpatient surgical coder and work on Interventional Radiology procedures and having the most specific data is the utmost importance. When laterality is not specified, the surgeon is queried, because not having laterality identified in the text of the document misses the ping effect I use as my guide, To me, without this information, the report is not complete and could possibly open more scrutiny by the insurance intermediary. The “ping” effect is when a specific location with laterality identifies the start of where the procedure begins and ultimately where the procedure ends. If any part of the beginning, middle, and end is not clear,hence nothing pings together. I also see the ramifications of non-clear report and that is if anyone else picked up the document to provide consult or opinion, there would be no clear identification of what transpired during the intervention.