AdministrativeAnthem Blue Cross and Blue Shield | CommercialMay 1, 2024

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 description.

For CMS 1500 form claims processed on or after May 30, 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 HCPCS modifier that does not correspond to the diagnosis.      

Example one:

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 (e.g., 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.

Example two:

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 lime 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. Ex Code: 00W19

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

We’re committed to active involvement with our care provider partners and going beyond the contract to create a real impact on the health of our communities.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield, and its affiliate HealthKeepers, Inc., serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123, are independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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PUBLICATIONS: May 2024 Provider Newsletter