In ICD-10, a unilateral diagnosis code is used to indicate a condition that affects only one side of the body, while a bilateral diagnosis code is used to indicate a condition that affects both sides of the body.
To code a unilateral diagnosis, you would typically use a code that specifically indicates the affected side. For example, if a patient has an injury to their left arm, you would use a code that includes the specific identifier for the left side. For instance, if the injury is a fracture of the left arm, the code would be S52.5- (with the fifth character being a specific digit indicating the type of fracture).
To code a bilateral diagnosis, you would typically use a code that indicates the condition affects both sides of the body. For example, if a patient has a bilateral hearing loss, you would use the code H90.3, which specifically indicates bilateral hearing loss.
It is important to note that not all codes have specific indicators for unilateral or bilateral conditions. In these cases, it may be necessary to use additional documentation or clinical judgment to determine whether the condition is unilateral or bilateral and choose the appropriate code accordingly.