A fracture note in an orthopedic clinic omits laterality that the ICD-10-CM classification requires. What should the coder do?
Select an answer to reveal the explanation.
Short Explanation
Laterality isn’t a coin flip—you can’t guess left versus right to finish a code. If the note forgot the side and the classification needs it, query or get the documentation fixed instead of inventing anatomy.
Full Explanation
When ICD-10-CM requires laterality, documentation must support the side selected. Coders must not assume left, right, or bilateral without clinical support. The correct path is clarification via query or amended documentation; omitting the fracture in favor of a pain symptom alone is not an appropriate workaround when fracture is documented.