New Medicare Correct Coding Edits

Date: 06/30/21

Effective for Dates of Service August 1, 2021 and After

Effective for dates of service August 1, 2021 and after, Allwell from Arizona Complete Health (Allwell) will implement the three medical claim edits detailed below.

Lateral Policy for Diagnosis to Diagnosis (LADX) and Mutually Exclusive Diagnosis Code Edit (MEDX) were developed based on ICD-10-CM Official Guidelines for Coding and Reporting. Procedure Modifier Revenue Necessary (PMRN) was developed based on CMS guidelines.

LADX and MEDX edits address coding inaccuracies including using an unspecified diagnosis code to indicate laterality when a more specific code is available, and mutually exclusive diagnosis codes. The PMRN edit will address the required use of modifiers when appropriate.

If you have questions regarding the information contained in this update, please feel free to contact our Provider Service Center at (866) 796-0542. If you need your assigned Provider Engagement Specialist contact information, please email us at: AzCHProviderEngagement@azcompletehealth.com

Description	Edit Function	Edit Details
Lateral Policy for Diagnosis to Diagnosis (LADX)	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 codes were associated.	Source: According to the ICD-10-CM Official Guidelines for Coding and Reporting, some ICD-10-CM codes specify whether the condition occurs on the left, right, or bilateral. If no bilateral code is provided and the condition is bilateral, then codes for both left and right should be assigned. If the side is not identified in the medical record, then the unspecified code should be assigned.
Mutually Exclusive Diagnosis Code Edit (MEDX)	A MEDX edit indicates that the excluded diagnosis code identified in the Excludes 1 Note of the ICD-10 Coding Manual should never be used at the same time as the code or code range listed above the Excludes 1 Note in the ICD-10 Coding Manual. Any line where these diagnosis codes are reported together will have the associated procedure code denied.	Source: ICD-10 Coding Manual. These notes are located under the applicable section heading or specific ICD-10-CM code in the ICD-10 Coding Manual to which the note is applicable. When the note is located after a section heading, then the note is applicable to all codes in the section. Only applies to professional claims (facility claims are excluded).
Procedure Modifier Revenue Necessary (PMRN)	The Procedure Modifier Revenue Necessary (PMRN) edit denies procedures that require an associated modifier. The edit also identifies situations where a correct modifier and a correct revenue code are required. This edit applies to professional (CMS 1500) and outpatient facility (UB-04) claims.	Source: CMS Manual. According to CMS and AMA, procedures performed on different sides of the body, separate anatomical areas, or separate patient encounters require the use of modifiers whenever appropriate. Special reminders for therapy claims: On professional claims, each code designated as “always therapy” must be provided under a physical therapy, occupational therapy, or speech-language pathology plan of care, regardless of who furnishes them. As such, the claims must always be accompanied by one of the therapy modifiers. For example, CMS recognizes services provided under the outpatient therapy services benefit as either “always” or “sometimes” therapy. “Always therapy” codes require modifier GN, GO, or GP appended to the therapy CPT code. CMS approved "sometimes therapy" codes require the appropriate modifier and revenue code combination when provided by a therapist.

Description

Edit Function

Edit Details

Lateral Policy for Diagnosis to Diagnosis (LADX)

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 codes were associated.

Source: According to the ICD-10-CM Official Guidelines for Coding and Reporting, some ICD-10-CM codes specify whether the condition occurs on the left, right, or bilateral. If no bilateral code is provided and the condition is bilateral, then codes for both left and right should be assigned. If the side is not identified in the medical record, then the unspecified code should be assigned.

Mutually Exclusive Diagnosis Code Edit (MEDX)

A MEDX edit indicates that the excluded diagnosis code identified in the Excludes 1 Note of the ICD-10 Coding Manual should never be used at the same time as the code or code range listed above the Excludes 1 Note in the ICD-10 Coding Manual. Any line where these diagnosis codes are reported together will have the associated procedure code denied.

Source: ICD-10 Coding Manual. These notes are located under the applicable section heading or specific ICD-10-CM code in the ICD-10 Coding Manual to which the note is applicable. When the note is located after a section heading, then the note is applicable to all codes in the section.
Only applies to professional claims (facility claims are excluded).

Procedure Modifier Revenue Necessary (PMRN)

The Procedure Modifier Revenue Necessary (PMRN) edit denies procedures that require an associated modifier. The edit also identifies situations where a correct modifier and a correct revenue code are required. This edit applies to professional (CMS 1500) and outpatient facility (UB-04) claims.

Source: CMS Manual. According to CMS and AMA, procedures performed on different sides of the body, separate anatomical areas, or separate patient encounters require the use of modifiers whenever appropriate.

Special reminders for therapy claims:

On professional claims, each code designated as “always therapy” must be provided under a physical therapy, occupational therapy, or speech-language pathology plan of care, regardless of who furnishes them. As such, the claims must always be accompanied by one of the therapy modifiers. For example, CMS recognizes services provided under the outpatient therapy services benefit as either “always” or “sometimes” therapy. “Always therapy” codes require modifier GN, GO, or GP appended to the therapy CPT code.

CMS approved "sometimes therapy" codes require the appropriate modifier and revenue code combination when provided by a therapist.