Knowledge Base Article

Did You Know?

CMS published Change Request (CR) 12471 in October 2021 to:

• Implement system changes needed to update the Shared System Maintainer (SSM) interface with the Java MCE to accept new MCE Edit 20-Unspecific Code Edit, and
• Provide a mechanism to systematically bypass the new edit when a specific billing note is present in the claim remarks field to indicate the primary reason laterality could not be determined.

This new edit became effective for hospital inpatient discharges occurring on or after April 1, 2022.

Why this Matters?

In ICD-10-CM there are unspecified codes for when documentation in the record does not provide detail needed to report a more specific code. “However, 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.”

Code Edit 20- is triggered when an unspecified diagnosis code currently designated as either a Complication or Comorbidity (CC) or Major Complication or Comorbidity (MCC), that includes other codes in that code subcategory that further specify the anatomic site, is entered.

This edit is meant to signal providers that there is a more specific laterality code available to report. It will be the provider’s responsibility to determine if documentation in the medical record supports a more specific code. “If, upon review, additional information to identify the laterality from the available medical record documentation by any other clinical provider is unable to be obtained or there is documentation in the record that the physician is clinically unable to determine the laterality because of the nature of the disease/condition, then the provider must enter that information in the remarks section.”

Mechanism to Bypass new MCE Edit 20-

Enter one of the following in the Remarks Field to enable your MAC to systematically bypass the edit and process your claim:

• UNABLE TO DET LAT 1 to show you are unable to obtain additional information to specify laterality, or
• UNABLE TO DET LAT 2 to show the physician is clinically unable to determine laterality.

   

  “If there is no language entered into the remarks section as to the availability of additional information to specific laterality and the provider submits the claim for processing, the claim would be returned to the provider.”

   

  Table 6P.3a associated with the FY 2022 IPPS/LTCH Final Rule contains the initial list of 3,432 ICD-10-CM unspecified codes.

   

  In the FY 2024 IPPS Proposed Rule, CMS has proposed the addition of new ICD-10-CM diagnosis codes that will be effective October 1, 2023 to the list of codes subject to Code Edit 20-.  Specifically, CMS has proposed adding:

• Twelve new ICD-10-CMS age related and other osteoporosis codes with current pathological fracture diagnosis codes (M80.0B9A, M80.0B9D, M80.0B9G, M80.0B9K, M80.0B9P, M80.0B9S, M80.8B9A, M80.8B9D, M80.8B9G, M80.8B9K, M80.8B9P, and M80.8B9S), and
• Four unspecified pressure ulcer codes that CMS identified as being inadvertently omitted from this list effective with discharges on or after April 1, 2022 (L89.103, L89.104, L89.93, and L89.94).

Why It Matters by the Numbers?

RealTime Medicare Data (RTMD), our sister company, maintains a database of Medicare Fee-for-Service paid claims data for all states and Washington, D.C. While I am unable to identify how many claims were returned to the provider, based on claims data, it appears that hospitals have significantly decreased the volume of claims that includes one of the 3,432 unspecified codes.

Six months Prior to implementation of Code Edit 20- (October 1, 2021 – March 2022 Data)

• 26,892: The volume of claims including one of the 3,432 unspecified codes,
• $485,063,597: The total payment for this group of claims.

   

  Six months Post April 1, 2022 Implementation of Code Edit 20- (April 1 – September 30, 2022)

• 2,244: The volume of claims including one of the 3,432 unspecified codes,
• $32,653,438: The total payment for this group of claims.

What Can I Do?

Share this information with key stakeholders at your facility (i.e., billing, coding, clinical documentation integrity specialists and watch for the release of the FY 2024 final rule later in the year to confirm that CMS finalized this proposal.