Wiki Anthem - Unspecified laterality will be denied effective 8/1/2023

[sls314]

We just got this provider news update for Anthem in Ohio. You'll want to check for Anthem updates in your area - I suspect that it could be across the board for Anthem.

Also, I wouldn't be surprised if other payers eventually follow suit. We've already seen many posters in the forums mention encountering claim denials from various payers.

From Anthem Provider News for Ohio:

Background
ICD-10-CM laterality codes are developed to precisely define laterality (for example, left, right, or bilateral). ICD-10-CM guidelines for laterality coding provide that some ICD-10-CM 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.

Impact to providers
Providers should code their claims to the highest level of specificity in accordance withICD‑10-CM coding guidelines for site and laterality when specified laterality codes exist and to submit the appropriate laterality code in accordance with the condition. Professional claims submitted on a CMS‑1500 form or facility claims submitted on CMS-1450 date of service on or after August 1, 2023, that do not reflect the highest level of specificity when the code exists will be denied.

https://providernews.anthem.com/ohio/articles/unspecified-diagnosis-code-of-site-and-laterality-11

 

[csperoni]

Thanks for the heads up.
In many cases, laterality definitely should be documented. However, there really are situations where the physician either doesn't know or doesn't document the laterality or it's uncertain.
Example - small midline ovarian simple cyst. The imaging thus far really does not indicate whether it is originating from the right ovary or the left ovary. They would not know for sure unless surgery is performed. And a small simple ovarian cyst frequently does not require surgery.
Example - ovarian cancer. Once the surgeon has removed the ovaries (and likely also fallopian tubes, uterus, etc.), to the oncologist administering chemo, it is irrelevant whether the cancer was on the left ovary or right ovary. The treatment is determined by the type of cancer cells (epithelial, germ cell, etc) and the grade and stage. Which by the way don't even have different codes. But laterality does not cross the mind of the clinician during chemo treatment.
This is going to get interesting educating providers!

 

[sls314]

Thanks for the heads up.
In many cases, laterality definitely should be documented. However, there really are situations where the physician either doesn't know or doesn't document the laterality or it's uncertain.
Example - small midline ovarian simple cyst. The imaging thus far really does not indicate whether it is originating from the right ovary or the left ovary. They would not know for sure unless surgery is performed. And a small simple ovarian cyst frequently does not require surgery.
Example - ovarian cancer. Once the surgeon has removed the ovaries (and likely also fallopian tubes, uterus, etc.), to the oncologist administering chemo, it is irrelevant whether the cancer was on the left ovary or right ovary. The treatment is determined by the type of cancer cells (epithelial, germ cell, etc) and the grade and stage. Which by the way don't even have different codes. But laterality does not cross the mind of the clinician during chemo treatment.
This is going to get interesting educating providers!

I haven't had a chance to listen yet, but I just saw that Terry Fletcher's CodeCast podcast episode this week will be discussing unspecified laterality. Will be curious to see how she covers the topic.