When do you need to include laterality in a diagnosis code?
If a code requires laterality, it must be included in order for the code to be valid, even if it’s “unspecified.” 1. Determine which, if any, laterality options each diagnosis code has. Some codes have left and right options, but not bilateral.
Is unspecified laterality still an issue in claims processing?
In fact, unspecified laterality continues to be an issue in claims processing. In addition to the reminder from Anthem mentioned above, CMS implemented a new code edit for ‘‘unspecified’’ codes in the 2022 Medicare Hospital Inpatient Prospective Payment Systems.
What changes will EmblemHealth implement in 2019 for laterality diagnosis coding?
Beginning January 1, 2019, EmblemHealth will implement two claim edits associated with laterality diagnosis coding. 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.
What happened to the grace period for claims with unspecified laterality?
That grace period expired on October 1, 2016, and some payers began denying claims that contained unspecified laterality. In fact, unspecified laterality continues to be an issue in claims processing.
How do you bill bilateral procedures for Medicare?
Medicare requires that when bilateral procedures are billed, they should be billed with one unit on one line with the 50 CPT modifier. The amount billed should reflect the cost of both the left and right side.
What is the modifier for laterality?
Use laterality modifiers to indicate that a procedure is performed on only one side of the two paired body parts. The modifiers are LT for left and RT for right. You would put one at the end of a code that needed the laterality defined. An example would be a corneal transplant on the right eye.
How do you bill for bilateral procedures?
Bilateral surgical and nonsurgical procedures are reported as a single code billed (1) with modifier 50, (2) twice on the same day with RT and LT modifiers, or (3) with 2 units. For Medicare plans, Aetna pays 150% of the fee schedule amount for a bilateral surgical procedure.
Are laterality modifiers required?
Article Guidance CPT® codes that are designated in their description as “unilateral or bilateral” do not require additional laterality modifiers.
How do you code laterality?
In ICD-10, laterality code descriptions include right, left, bilateral, or unspecified designations:Right side = character 1;Left side = character 2;Bilateral = character 3;Unspecified side/region = character 0 or 9 (depending on whether it is a 5th or 6th character).
Does Medicare accept modifier LT and RT?
Several DME MAC LCD-related Policy Articles require the use of the RT and LT modifiers for certain HCPCS codes. The right (RT) and left (LT) modifiers must be used when billing two of same item or accessory on the same date of service and the items are being used bilaterally.
What modifier is used for bilateral procedure?
Modifier 50Modifier 50 applies to bilateral procedures performed on both sides of the body during the same operative session. When a procedure is identified by the terminology as bilateral or unilateral, the 50 modifier is not reported.
Is there a bilateral modifier?
Use modifier 50 to report bilateral procedures performed during the same operative session by the same physician in either separate operative areas (e.g., hands, feet, legs, arms, ears) or in the same operative area (e.g., nose, eyes, breasts).
How do I bill bilateral knee injections to Medicare?
Indicate which knee was injected by using the RT (right) or LT (left) modifier (FAO-10 electronically) on the injection procedure (CPT 20610). Place the CPT code 20610 in item 24D. If the drug was administered bilaterally, a -50 modifier should be used with 20610.
Does modifier 59 go before RT?
Contributor. different shoulders, modifiers RT and LT should be used, not modifier 59. LT and RT have not effect on the actual processing of the claim for payment, because they are informational.
Which modifier goes first 50 or 59?
The first pair of codes in Table C relate to the example previously reviewed. In this example, the procedures were performed on different sites, so the use of modifier 59 is correct.
What is the LT modifier used for?
Modifier LT This modifier is used to identify procedures performed on left side of body. Be sure to determine if HCPCS modifier LT is applicable for a particular procedure code. It does not affect allowed amount on a claim; however, lack of a required modifier can cause denials or development to occur.
Which way is right? Or left?
To better understand the unspecified rule, we first need to think within the framework of ICD-9-CM. This coding system did not lend itself to documenting laterality – meaning, if a patient came in with a fractured wrist it would be documented as “unspecified fracture of unspecified wrist and hand.”
How the unspecified rule impacts reimbursements
When an inpatient claim is submitted with an unspecified laterality code when specified laterality codes are available, the claim could be denied and sent back to the facility with edits. This, in turn, can impact an organization’s financial return and create clinical workflow challenges.
Analyze the impact of the unspecified rule
Organizations can run an analysis of how often their clinical documentation contains unspecified laterality leading to the assignment of unspecified codes that have sub-categories for laterality.
Specificity is the best policy
When it comes to these types of Medicare code edits, ones that raise the bar for capturing specificity within coding systems, the unspecified rule regarding laterality is just the beginning.
What does H60.332 mean?
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.
When will EmblemHealth implement unspecified code?
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.
When a patient has a bilateral condition and each side is treated during separate encounters, what is the code?
When a patient has a bilateral condition and each side is treated during separate encounters, assign the "bilateral" code (as the condition still exists on both sides), including for the encounter to treat the first side.
What is a CPT modifier?
The CPT code describes the side of the body the exam or procedure is performed on and the diagnosis describes the side of the body affected by a condition.#N#As an example, an exam may be of the left breast but the patient may have right breast cancer with pain in the left breast. In this situation the exam would have a LT modifier but the cancer diagnosis would be of the right breast. The CPT modifiers serve a separate purpose than the diagnosis laterally.
Can a bilateral code be assigned for a subsequent encounter?
The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition in the previously-treated site. If the treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate. Click to expand...
Why is bilateral adjustment inappropriate?
The bilateral adjustment is inappropriate for codes in this category (a) because of physiology or anatomy, or (b) because the code description specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure. 1.
Is RVU bilateral or bilateral?
The RVUs are based on a bilateral procedure because (a) the code descriptor specifically states that the procedure is bilateral, (b) the code descriptor states that the procedure may be performed either unilaterally or bilaterally, or (c) the procedure is usually performed as a bilateral procedure. 3.
Coding for Compression
For garments that provide 30-50 mmHG, the appropriate HCPS code is A6545 (Gradient compression wrap, non-elastic, below knee, 30-50 mmHg, each). It is important that the diagnosis codes pointing to A6545 represent a lower extremity ulcer requiring compression.
Do Not Forget the Modifiers!
When billing for compression, the -A modifier referred to in last month’s blog should not be used. Instead, the A6545 code must have an -AW modifier appended to it (Item furnished in conjunction with a surgical dressing.).
Example
An example of proper coding when the EXTREMIT-EASE Compression Garment is dispensed would be:
Resources
DISCLAIMER: The information provided here is intended to educate health care providers regarding compliance for diagnosis and CPT coding. The information provided does not guarantee reimbursement and is accurate to the best of our knowledge at the time of this publication. Coding guidelines can change and we encourage you to stay up to date.
What Is Laterality
Tips For Coding Laterality
- 1.Determine which, if any, laterality options each diagnosis code has. Some codes have left and right options, but not bilateral. Some codes do not have laterality options at all. If a condition affects one or both sides, determine how specific you need to be in your code selection. 2. Be as specific as possible. For instance, if a code has left, right, and bilateral options, and the conditio…
History of Coding Laterality
- The specificity of laterality was actually highlighted as one of the benefits of ICD-10 when it was first being implemented, though it also presented a higher burden for documentation than some providers were used to. As a result, CMS implemented a 12-month grace period, during which claims would not be denied for failing to include the most specific laterality, according to Pat Ma…
Learn More
- For more information on laterality, check out Healthcare Training Leader’s blog post: Laterality Frequently Unlocks ICD-10-CM Code Accuracy. You can also review the ICD-10-CM Official Guidelines for Coding and Reporting, approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American …