Sonja Posted Wed 10th of July, 2019 11:23:45 AM
We had a Dx denial issue with a claim for 2019 but the insurance carrier isn't specifying where the problem is. Our claim has codes I82.411, I82.412, R53.2, and G30.1. I was thinking it could be because we used both the left and right side Dx codes I82.411 and I82.412 instead of using the bialteral Dx code I82.413. In situations where it is both left and right, should we be using the bilateral code instead? The procedure was for a nursing home visit and nothing else was performed.
SuperCoder Answered Thu 11th of July, 2019 09:00:37 AM
Thanks for your question.
As per ICD-10 CM guidelines some codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side. 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. For the second encounter for treatment after one side has previously been treated and the condition no longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists (e.g., cataract surgery performed on each eye in separate encounters). 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.
Secondly, code I82.411 and I82.412 codes are HAC (hospital acquired condition) codes which means the problem was acquired during hospital settings. Some payers doesn't pay for any of these conditions, and patients can't be billed for them, if acquired while in the hospital.
Thirdly, you might have to check with MEAT guidelines that needs to be achieved for appending these ICD-10 CM codes.
You can also ask your payer to provide explanation of benefit (EOB) which may specify reason for denial.
Hope this helps.