Avoiding inaccurate coding combinations of laterality and diagnosis

As previously noticed in our March 2020 provider newsletter tinyurl.com/mr3n9nw2, providers must code their claims to the highest level of specificity in accordance with industry standard coding guidelines, such as ICD-10-CM coding guidelines and reporting. When an ICD-10-CM diagnosis code has a specified anatomical laterality within the code description, the anatomical modifier that is appended to a CPT^® or HCPCS code must correspond to the laterality within the ICD-10-CM description to identify different areas of the body that were treated. Proper application of the anatomical modifiers helps ensure the highest level of specificity on the claim and can help show that different anatomic sites received treatment.

Professional claims submitted on a CMS 1500 form, for claims processed on or after May 1, 2024, Anthem will apply these correct coding ICD-10-CM guidelines and deny claim lines that have a laterality diagnosis submitted with a CPT or HCPC modifier that does not correspond to the diagnosis. 

These are some improper coding examples:

• Reported diagnosis: E11.3593 (Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral)
  Billed CPT code: 67228-RT Treatment of extensive or progressive retinopathy (for example, diabetic retinopathy), photocoagulation.
  Determination: It is not appropriate to report an RT modifier when the laterality of bilateral is identified in the ICD-10 diagnosis. Therefore, the claim line will be denied.
• Reported diagnosis: S91.011A (Laceration without foreign body, right ankle, initial encounter)
  Billed CPT code: 27786-LT (Closed treatment of distal fibular fracture: lateral malleolus; without manipulation)
  Determination: It is not appropriate to report an LT modifier when the laterality of right is identified in the ICD-10 diagnosis. Therefore, the claim line will be denied.

Additionally, the ICD-10-CM diagnosis code should correspond to the medical record, CPT,^® HCPCS code(s), and/or modifiers billed.

Anthem will continue to enhance its editing system to automate edits and simplify remittance messaging supported by correct coding guidelines. The enhanced editing automation will promote faster claim processing and reduce follow-up audits and/or record requests for claims not consistent with correct coding guidelines. If you have questions about this communication or need assistance, contact your provider relationship management representative.

EOB message — Diagnosis codes with a specified laterality description should be submitted with the appropriate modifier of specificity and procedure code. Ex code: 00W19

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