Coding Bilateral Conditions Treated During Separate Encounters

When a patient has a bilateral condition and each side is treated during separate encounters, assign the bilateral code, as the condition still exists on both sides, including for the encounter to treat the first side.

For the second encounter for treatment after 1 side has previously been treated and the condition no longer exists on that side, assign the unilateral code for the side where the condition still exists.

For example, this would apply to cataract surgery performed on each eye in separate encounters. You wouldn’t assign the bilateral code for the subsequent encounter because the patient no longer has the condition in the earlier treated site.

If the treatment on the first side didn’t completely resolve the condition, then the bilateral code would still be applicable.