Enhanced Correct Coding Guidelines

Date: 07/19/24

Enhanced Correct Coding Guidelines

Effective 9/1/2024 for Medicaid, Marketplace and Medicare lines of business, we’re enhancing correct coding edits based on industry standards and coding rules consistent with the national ICD-10 CM Diagnosis Code Manual  and  our  internal  Coding  Overview  (CC.PP.011)  Payment  Policy.  These  rules  are  used  by  most healthcare claims payers and enforced by the Center for Medicare and Medicaid Services (CMS).

Edit Name	Edit Description	Denial Reason Code
Mutually Exclusive Diagnosis Code (MEDX) Edit	A MEDX edit indicates that the excluded diagnosis code identified in the Excludes 1 Note should never be used at the same time as thecode or code range listed above the Excludes 1 Note located under the application section heading or specific ICD-10-CM code to which the note is applicable. When the note is located following a section heading, then the note is applicable to all codes in the section. Any line where these diagnosis codes are reported together will have the associated procedure code denied. Only applies to professional claims.	EX Code: wd Diagnosis Code Incorrectly Coded Per ICD10 Manual
Lateral Policy for Diagnosis to Diagnosis (LADX) Edit	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 will be applied to the procedure code to which the diagnosis code(s) were associated.	EX Code: wd Diagnosis Code Incorrectly Coded Per ICD10 Manual
Lateral Policy for Diagnosis to Modifier Mismatch(LAMD) Edit	The LAMD edit denies claim lines where amismatch between diagnosis code and the procedure modifier appended to the line exists as defined by the ICD-10 Manual with reason of Diagnosis Code(s) inappropriately coded	EX Code: wd Diagnosis Code Incorrectly Coded Per ICD10 Manual

The Coding Overview Payment Policy (CC.PP.011) can be found in our website.

If an AHCCCS coverage provision should conflict with a provision(s) in policy CC.PP.011, the AHCCCS coverage provision shall take precedence for Medicaid. Applicable Medicare National Coverage Determinations and Local Coverage Determinations will be reviewed prior to applying the criteria in policy CC.PP.011 to Medicare claims. Refer to the CMS website for additional information.

AzCH providers and staff:

If you have questions, please contact your AzCH Provider Engagement Specialist. If you need your assigned Provider Engagement Specialist’s contact information, please email us at AzCHProviderEngagement@azcompletehealth.com.

Care1st providers and staff:

If you have questions, please call Network Management at 1-866-560-4042 (Options in order: 5, 7) or email SM_AZ_PNO@care1staz.com.