Mga Tagapagbigay

ICD 10 Correct Coding Edits

March 8, 2023

Dear Provider,

This letter is to inform you of ICD-10 correct coding edits that are in place:

• CE329: Per ICD-10 the combined diagnosis codes cannot be reported together
• IH147: Inconsistent ICD-10/Modifier or Mutually Exclusive Diagnosis

The following edits are supported by Policy CC.PP.011. The Source material for the Policy and edits is the ICD-10 Manual.

How will I identify these denials?

When a billed line is denied for one of these ICD-10 rules, your Explanation of Payment (EOP) will be annotated with “DIAGNOSIS CODE INCORRECTLY CODED PER ICD10 MANUAL.”

What are the ICD-10 rules that I should monitor?

The following rules may apply to your claims:

1. Secondary Diagnosis Edit: If any procedure or service is billed and the Primary, First-Listed, Principle or Only Diagnosis is one of the ICD-10 codes designated as Secondary, then the PSDD edit will be applied to the procedure or service. This edit will not apply to specific DME specialties.
2. Mutually Exclusive Diagnosis Code Edit: The edit indicates that the excluded diagnosis code identified in the Excludes 1 Note should never be used at the same time as the code or code range listed above the Excludes 1 Note. Any line where these diagnosis codes are reported together will have the associated procedure code denied.
3. Lateral Policy for Diagnosis to Diagnosis: Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. It is not appropriate to report unspecified, or left and right diagnosis codes when a more specific (e.g., bilateral) code is available. The LADX edit denies a claim line when a procedure code is used and the associated diagnosis code is not specifying the laterality of the condition.
4. Lateral Policy for Diagnosis to Modifier Mismatch: The edit denies claim lines when there is a mismatch between the diagnosis code and the procedure code modifier appended to the line. This is defined in the ICD-10 Manual with reason Diagnosis Code(s) Inappropriately coded.
5. Manifestation Diagnosis Codes: If any procedure or service is billed and the Primary, First-Listed, Principal or Only Diagnosis is a manifestation code, the procedure code is denied because a manifestation code is a diagnosis of some other underlying disease, not the etiology (cause) of the disease itself. The edit will be applied to the procedure or service with reason Primary, First-Listed, Principal or Only Diagnosis Inappropriately Coded.
6. Sequela Diagnosis Edit: If any procedure or service is billed and the Primary, First-Listed, Principle or Only Diagnosis is one of the ICD-10 codes designated as Secondary, then the edit will be applied to the procedure or service. This edit will not apply to specific DME specialties.
7. Manifestation Diagnosis Codes: If any procedure or service is billed and the Primary, First-Listed, Principal or Only Diagnosis is a manifestation code the procedure code is denied because a manifestation code is a diagnosis of some other underlying disease, not the etiology (cause) of the disease itself. The edit will be applied to the procedure or service with reason Primary, First-Listed, Principal or Only Diagnosis Inappropriately Coded.
8. External Causes Diagnosis Edit: If any procedure or service is billed and the Primary, First-Listed, Principal or Only Diagnosis is a manifestation code the procedure code is denied because a manifestation code is a diagnosis of some other underlying disease, not the etiology (cause) of the disease itself. The edit will be applied to the procedure or service with reason Primary, First-Listed, Principal or Only Diagnosis Inappropriately Coded.
9. Evaluation and Management with Preventive and Z Diagnosis Code Policy: The edit denies the Evaluation and Management service when it is reported with a Preventive Medicine Evaluation and Management service and ICD-10 Z diagnosis code(s) are the only diagnosis codes on the lines. Or the edit denies the Preventive Medicine Evaluation and Management service when it is reported on the same date of service, for the same patient, by the same provider, as an Evaluation and Management service and ICD-10 Z diagnosis codes are the only diagnoses on the lines.
10. Invalid Diagnosis Edit: The diagnosis code(s) reported are invalid on the line as they are either an incomplete, a not-active, or a non-existent ICD-10 diagnosis code. The procedure reported with the invalid ICD-10 diagnosis code will have an this edit applied and the procedure code will be denied.

• Incomplete: DX code reported is not coded to the highest level of specificity based on Date of Service.
• Not Active: DX code reported for DOS before its effective date or after the termination date.
• Non-Existent: DX code reported that has never been a valid ICD-10 diagnosis code.

Please Note: This list is representative of the top ICD-10 denials that we monitor. Other rules may also apply. For a definitive listing of ICD-10 rules and exclusions, check your ICD-10 Manual or online. If you have any questions, please reach out to your PR Representative.