Audience: Participating Professional Providers
Excellus BlueCross BlueShield will implement two claim edits associated with laterality diagnosis coding effective September 1, 2022.
According to ICD-10-CM Manual guidelines, some diagnosis codes indicate laterality, specifying whether the condition occurs on the left or right, or is bilateral.
One of the unique attributes of the ICD-10-CM code set is that laterality is built into code descriptions. Some ICD-10-CM codes specify whether the condition occurs on the left or right or is bilateral. If no bilateral code is provided and the condition is bilateral, then codes for both left and right should be assigned. If the side is not identified in the medical record, then the unspecified code should be assigned.
Effective September 1:
- 1. Diagnosis-to-Modifier: The diagnosis-to-modifier comparison assesses the lateral diagnosis associated to the claim line to verify that the procedure modifier matches the lateral diagnosis.
DIAG1: H60.332 (Swimmer’s ear, left ear)
CPT: 69000 (Drainage external ear, abscess, or hematoma; simple) MOD: RT
Explanation: The diagnosis code is inappropriately coded. H60.332 indicates left ear, but the modifier indicates right ear; therefore, beginning September 1, this claim line would be denied because diagnosis H60.331 (Swimmer's ear, right ear) should have been billed.
- Diagnosis-to-Diagnosis: The diagnosis-to-diagnosis comparison assesses lateral diagnoses associated to the same claim line to verify that the combination is appropriate.
DIAG1: H60.331 (Swimmer’s ear, right ear)
DIAG2: H60.333 (Swimmer’s ear, bilateral)
CPT: 69000 (Drainage external ear, abscess, or hematoma; simple)
Explanation: Duplicative diagnoses are being billed. Only diagnosis H60.333 should have been billed; therefore, beginning September 1, the claim line would be denied.
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