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.

On a CMS 1500 form, for professional submitted claims processed on or after July 7, 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.

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 (for example, diabetic retinopathy), photocoagulation.
• Determination: It is not appropriate to report the RT modifier when the laterality of bilateral is identified in the ICD-10-CM 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 a 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.

EOB message

Diagnosis codes with a specified laterality description should be submitted with the appropriate modifier of specificity and procedure code. Ex codes: v19 and 00V19

If you have questions about this communication or need assistance, contact your provider relationship account manager. We are committed to a future of shared success.