Unspecified diagnosis reminder

This is a reminder to all providers that we require laterality-specific coding when applicable. Therefore, claims processed on or after October 1, 2021, will be denied when ICD-10-CM laterality coding guidelines are not followed.

 

In accordance with the International Classification of Disease, 10th Revision, clinical modification (ICD-10-CM) correct coding guidelines, in which state Medicaid programs follow, we will begin to edit diagnosis in Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue for appropriate laterality billing.

 

ICD-10-CM diagnosis coding falls under Health Insurance Portability and Accountability Act (HIPAA) correct code sets and they are designed to specifically define laterality (e.g., left, right, unspecified, or exists bilaterally, etc.). Providers are required to submit the defined code in accordance with the condition. The ICD-10-CM guidelines for Coding and Reporting state (for Laterality coding), “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.”

 

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

 

If you have questions about this communication or need assistance with any other item, call Provider Services at 855-558-1443.

 

AWI-NU-0310-21