By Cynthia Tang, RHIA, CCS

There is a Medicare Code Editor (MCE) New Edit 20 effective April 1, 2022 for certain diagnosis codes if the laterality is not specified. For example: pressure ulcer of unspecified elbow; intracapsular fracture of unspecified femur.

These Medicare Code Edits detect and report errors in the coding claims data. They include submitting a claim with an invalid diagnosis or procedure code, E-code as principal diagnosis, sex conflict, invalid age, etc. These edits must be corrected before the claim is paid by Medicare.

This new edit is specifically for certain diagnosis codes that have “unspecified” laterality, and not assigned as left, right, or bilateral (click here to download a complete list of diagnosis codes that have unspecified laterality). The MCE states: “In the inpatient setting, there should generally be very limited and rare circumstances for which the laterality (right, left, bilateral) of a condition is unable to be documented and reported.”

We agree that in the inpatient setting this would be a rare circumstance since laterality would almost always be documented in the record, such as a diagnostic report (x-ray, CT, angiogram, etc.), or other provider documentation. Diagnostic reports and other provider documentation can be used to assign laterality.

We specifically address this situation in our CDI Pocket Guide®:

Although perhaps not widely understood, it has been an acceptable inpatient coding practice to assign greater specificity of established diagnoses based on diagnostic studies that have been interpreted by a physician.

According to Coding Clinic, First Quarter 2013, p. 28, “If the x-ray report provides additional information regarding the site for a condition that the provider has already diagnosed, it would be appropriate to assign a code to identify the specificity that is documented in the x-ray report.”

The same can be said for other situations where ICD-10 provides greater specificity for an established diagnosis such as:

    • Laterality and involved artery for a diagnosed nonspecific CVA from CT or MRI/MRA
    • Location of involved artery for an unspecified diagnosis of STEMI obtained from the EKG
    • Laterality of hip fracture from x-ray

When is a query needed?

A provider query should rarely be needed if the laterality information is documented somewhere in the record, such as within diagnostic reports or other provider documentation. In the rare instance where laterality is not found by the coding staff, we recommend flagging this as a deficiency as part of the “medical record deficiency” process within the health information management department. This is the process that assigns deficiencies for missing documentation such as discharge summaries, surgical diagnosis on an operative report, or electronic signatures.

If not included in the medical record deficiency process a simple query asking the provider to state whether a particular condition is left, right or bilateral is all that would be needed.

Remember that a good compliance “rule of thumb” is to never assign greater specificity from an interpreted diagnostic test result without provider documentation if the greater specificity would impact the DRG resulting in higher payment. For example, documented heart failure but the echocardiogram report shows “diastolic dysfunction.” Do not go ahead and assign diastolic heart failure, instead query the provider.

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CDI Pocket Guide® updated for 2023
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