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Question: There are several types of osteoarthritis (OA), lots of places it can manifest, and  several ICD-10-CM codes offering specificity. However, I don鈥檛 see any codes that explicitly mention bilateral OA. One of our provider鈥檚 notes for a patient says the patient has OA in both shoulders. How do I report this condition?

Arkansas Subscriber

Answer: Look to M19.- (Other and unspecified osteoarthritis) for the ICD-10-CM codes for osteoarthritis in the shoulder, and you鈥檒l find the diagnosis options for this condition:

• M19.01- (Primary osteoarthritis, shoulder)
  • 鈥婱19.011 (Primary osteoarthritis, right shoulder)
  • M19.012 (Primary osteoarthritis, left shoulder)
  • M19.019 (Primary osteoarthritis, unspecified shoulder)

You鈥檒l notice that while there are codes for the right, left, and an unspecified shoulder, there is no code to denote both shoulders being affected. In this situation, you should follow ICD-10-CM general coding guideline I.B.13: 鈥淚f no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.鈥�

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, 星空入口