Inaccurate laterality and diagnosis combination

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 laterality within the code description, the modifier that is appended to a CPT^® or HCPCS code must correspond to the laterality within the ICD-10-CM description.

For professional claims submitted on a CMS-1500 form processed on or after November 15, 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. See examples below.

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 (such as 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-CM 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.

Diagnosis codes with a specified laterality description should be submitted with the appropriate modifier of specificity and procedure code.

If you have questions about this communication or need assistance, contact your provider relationship account manager.