Marguerite Posted Tue 04th of September, 2018 13:32:37 PM
Anthem Blue Cross of CA I believe is committing fraud by constantly denying our clean and valid claims that have been billed with only E&M CPT, 99213 with ICD-10 codes G51.91 & G57.62 stating that "claim is denied because the procedure code 99213 does not match these diagnosis codes because they do not indicate Left or Right or Bilateral". One representative actually told me that these ICD-10 codes need modifiers! Am I missing something here as far as why these are constantly being denied? Blue Cross will not re-process any of these claims over the phone and state I must mail a handwritten appeal that will take 30-45 business days to process. What am I appealing to them exactly? This makes no sense to me and I would appreciate clarification please. Thank you!
SuperCoder Answered Wed 05th of September, 2018 02:42:56 AM
Thank you for your question.
As per the provided documentation, we only require a modifier with CPT/HCPCS codes and not with the ICD-10 codes.
Also, per the above documentation, ICD-10 code G51.91 does not exist in the available ICD code set. We are assuming that G51.91 is a typo error, and you mean ICD-10 code G57.61, which states: Lesion of plantar nerve, right lower limb.
The only difference between both the codes (G57.61 and G57.62) are of laterality (left and right).
ICD-10 CM codes are laterality specific, hence, modifiers will only be applicable with the procedure performed (i.e. CPT code) for the treatment of diagnosis, not with the ICD-10 code.
Therefore, ICD-10 code G57.63 (Lesion of plantar nerve, bilateral lower limbs) should be the appropriate code that need to be billed along with the E/M service code (99213) for the billed date of service. Furthermore, per coding guidelines, when a more appropriate ICD-10 code is available, then the service should not be reported with two separate ICD-10 codes.
Note: CPT code 99213 is not eligible for modifier LT/RT/50 as this is an evaluation and management code. These modifiers are applicable for the procedure code only.
Hope it helps.
Please feel free to ask any further question; if any.