July 18, 2019
In August 2019, we are introducing ICD-10 CM and CPT coding edits to support correct coding of services you submit for reimbursement. These edits will enforce coding guidelines as established in the ICD-10 CM Diagnosis codebook and the CPT Professional Codebook. New edits include the following:
Inappropriate modifier to Diagnosis Combination
This edit will identify diagnosis code and procedure code combinations that aren’t appropriate, specifically identifying a conflict with the laterality or anatomic location of the diagnosis code and laterality or anatomic location modifier submitted on a procedure code.
Some ICD-10 CM diagnosis codes indicate laterality, such as LEFT or RIGHT or BILATERAL which may conflict with the anatomic modifiers attached to the procedure code.
Example:
- Diagnosis S42.351-Displaced comminuted fracture of shaft of humerus, right arm
- Procedure 24505-LT – Closed treatment of humeral shaft fracture; with manipulation; with/without skeletal traction
The diagnosis indicates Right arm but the procedure shows a Left modifier
This edit will also apply when the Diagnosis code on the claim line indicates “unspecified side” but the procedure code is billed with a specific anatomic modifier that identifies a specific side, a specific finger or toe or a specific location on the eye.
Review the Payment Policy, Site Specifying Modifiers, for further details on how to use the anatomic location modifiers.
Inappropriate use of repeat lab test modifier 91
A repeat lab test is identified by the appending of modifier 91 to a lab series code. The description for modifier 91 indicates that during treatment of the patient, it was necessary to repeat the same laboratory test on the same day to obtain subsequent or multiple test results. Per the modifier description, adding modifier 91 to a lab test indicates there should be another “initial” billing of the same code without modifier 91 in claims history.
This edit will validate in claims history to determine whether that initial billing of the same lab test billed on the same date of service can be found. If it can’t be found, the lab test submitted with modifier 91 will deny reimbursement as incorrect modifier to procedure combination.
Incomplete Diagnosis code
One of the most significant features of ICD-10 CM Diagnosis codes is the level of specificity found in the selection of codes. A complete and accurate code is coded to the highest level of specificity as determined by the selection of the 4th, 5th, 6th or 7th digit available on a diagnosis code as defined in the ICD-10 CM codebook.
Example:
- Nonspecific: S82.6 – Fracture of lateral malleolus
- Coding Guidelines indicate 7th digit is required for this diagnosis
- Specific: S82.62XD – Displaced fracture of lateral malleolus of left fibula, subsequent encounter for fracture with routine healing
This edit will enforce the coding guidelines for ICD-10 CM Diagnosis codes to ensure that the diagnosis codes billed are to the highest level of specificity or the most accurate number of digits available to correctly define the diagnosis as identified in the codebook. Incomplete diagnoses missing required digits, per ICD-10 CM Official Guidelines, will be denied reimbursement.
To learn more or to review coding criteria associated with these upcoming edits, check the following resources: