Over the next few issues we will identify the top reasons claims are delayed or denied and how you as the provider can assist in getting your work billed with fewer queries from your coder.
This month we will focus on coding for laterality for diagnosis coding as this has been identified as a significant opportunity and is a key element of the coding and the reimbursement process. All services must be medically necessary, the diagnosis code will identify the medical necessity for the visit or service and must be supported by the documentation.
Modifiers and diagnosis codes that show laterality are VERY important. The documentation is often specific to a particular side of the body but many times the diagnosis code that was chosen will state "unspecified." Payors are denying "unspecified" diagnosis codes.
Tip: Code to the highest specificity supported by your documentation.
1.) Diagnosis codes often include the side of the body that is involved in today’s visit, right, left, or bilateral. Document the specifics then code to the highest specificity per the documentation.
a. Problem: Malignant Neoplasm of the breast
i. Which part of the breast is involved: nipple and areola, central portion, quadrant
ii. Laterality: right or left breast
iii. Identify sex: male or female breast
Example: C50.211 – Malignant neoplasm of upper-inner quadrant of right female breast
19303 RT - Attach the RT modifier to the surgical procedure to indicate
the right side.
2.) Fractures – bone, which part of the bone, type of fracture, which side (right or left), closed or open, displaced or nondisplaced, visit type (initial or subsequent), healing – routine, delayed, nonunion, malunion; sequela
a. Problem: fracture of ulna
i. Which part of the ulna: upper end, lower end. shaft
ii. Type of fracture: greenstick, transverse, oblique, spiral, etc.
iii. Displaced or nondisplaced
iv. Laterality: right or left
Example: S52.242A – Spiral fracture of the shaft of ulna, displaced, left arm, initial encounter
Note: The 7th Digit of ‘A’ for initial encounter is used for each encounter where the patient is receiving active treatment for the condition.
25535 LT - Attach the LT modifier to the fracture care code to indicate the left side.
The use of "unspecified" diagnoses will not only delay the performing provider’s claim but also the radiologist’s claims when ordering additional tests and studies. It has a domino effect.