What are brackets used for in medical coding?

Brackets [ ] in medical coding are used for several purposes:

Clarification: Brackets are used to include additional information or specifications that are not essential for the code's primary purpose. This clarification can help ensure accuracy and specificity in coding.

Missing or Uncertain Information: Brackets are used when there is missing or uncertain information in the medical record that is necessary to assign the correct code. The additional information may be obtained from the provider, other sources, or clinical judgment.

Unspecified Laterality: When a procedure is performed on an unspecified side or structure and laterality (left or right) is not specified in the medical record, brackets are used to indicate this.

Quantity or Measurement: Brackets can be used to enclose a quantity, measurement, or specific value related to the coded procedure or diagnosis. This helps in accurate documentation of the extent or intensity of the service provided.

Examples:

[Left] Knee Arthroplasty: Indicates a knee arthroplasty procedure performed on the left knee.

Percutaneous Coronary Intervention [3 Lesions]: Specifies the number of lesions treated during a percutaneous coronary intervention procedure.

Lumbar Puncture [L3-L4]: Indicates that the lumbar puncture was performed between the L3 and L4 vertebrae.

Fracture of Humerus [Distal Third]: Provides further information about the fracture location within the humerus.