Unspecified diagnosis code of site and laterality

Background

ICD-10-CM laterality codes are developed to precisely define laterality (for example, left, right, or bilateral). ICD-10-CM guidelines for laterality coding provide that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side.

Impact to providers

Providers should code their claims to the highest level of specificity in accordance with ICD‑10-CM coding guidelines for site and laterality when specified laterality codes exist and to submit the appropriate laterality code in accordance with the condition. Professional claims submitted on a CMS‑1500 form or facility claims submitted on CMS-1450 date of service on or after August 1, 2023, do not reflect the highest level of specificity when the code exists will be denied.

Example:

• Reported diagnosis: H60.339 (swimmer’s ear, unspecified ear)
• Billed CPT^® code or modifier: CPT 69000-RT (drainage external ear, abscess, or hematoma: simple [right side])
• Determination: It is not appropriate to report unspecified diagnosis codes when a more specific (for example, H60.331 swimmer’s ear, right ear) code is available; 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 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, or call Provider Services.