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EmblemHealth Policy Change Effective 01/01/2019: Correct Laterality ICD-10-CM Diagnosis Coding Policy

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According to the 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 to the ICD-10-CM code set is that laterality has been 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.
Beginning January 1, 2019, EmblemHealth will implement two claim edits associated with laterality diagnosis coding.
1. Diagnosis-to-Modifier – The Diagnosis-to-Modifier comparison assesses the lateral diagnosis associated to the claim line to determine if the procedure modifier matches the lateral diagnosis.

Example:
LINE 1:
DIAG1: H60.332 (Swimmer’s ear, left ear)
DOS: 10/20/2015
CPT: 69000 (Drainage external ear, abscess or hematoma; simple) MOD: RT
UNITS: 1

Explanation: The diagnosis code is inappropriately coded. H60.332 indicates left ear, but the modifier indicates right ear; therefore, the claim line will be denied since the provider should have billed diagnosis H60.331 (Swimmer’s ear, right ear) instead.

2. Diagnosis-to-Diagnosis – The Diagnosis-to-Diagnosis comparison assesses lateral diagnoses associated to the same claim line to determine if the combination is inappropriate.

Example:
LINE 1:
DIAG1: H60.331 (Swimmer’s ear, right ear)
DIAG2: H60.333 (Swimmer’s ear, bilateral)
DOS: 10/30/2015
CPT: 69000 (Drainage external ear, abscess or hematoma; simple)
MOD: 50
UNITS: 1

Explanation: The provider is billing duplicative, redundant diagnoses. Only diagnosis H60.333 should have been billed; therefore, the claim line will be denied.
Exceptions
• Osteoplasty, femur shortening procedure 27465 since it is performed to correct limb length discrepancy by shortening the longer limb, but the leg length discrepancy diagnoses ICD-10 codes M21.7 and Q72.8 are reported based on the contralateral (shorter) limb.
• Placement of selective, venous, arterial access catheters 36222-36228, 36555-36598, 36600-36640 and bone marrow aspiration, biopsy, harvesting procedures 38220-38221, 38230-38232 since they are routinely performed for treatment of an underlying condition (often a malignancy) that is affecting an anatomic site distinct from the site of the procedure.
• Diagnosis codes for female malignant neoplasms of the breast since prophylactic bilateral mastectomy procedures may be performed for unilateral breast cancer.