Knowledge Base Article

Did You Know?

It has been almost two years since the October 2021 release of the CMS Change Request (CR) 12471 (https://www.cms.gov/files/document/R11059CP.pdf). There were two stated purposes for this CR noted in the Summary of Changes: 

• 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 why laterality could not be determined.

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.”

Effective for claims with dates of service on or after April 1, 2022, new Code Edit 20- will be 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.

You will find the initial complete list of 3,432 ICD-10-CM unspecified codes subject to this edit in table 6P.3a associated with the FY 2022 IPPS/LTCH Final Rule (https://www.cms.gov/medicare/acute-inpatient-pps/fy-2022-ipps-final-rule-home-page).

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-

The provider may enter a remark:

• Either “UNABLE TO DET LAT 1” to indicate that they are unable to obtain additional information to specify laterality, or
• “UNABLE TO DET LAT 2” to indicate the physician is clinically unable to determine laterality. 

Entering this language will enable your MAC to systematically bypass the edit and process your claim.

However, “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.”

New Unspecified Codes Subject to MCE Edit 20-

In the FY 2024 IPPS Final Rule, CMS finalized the addition of six new diagnosis codes that are designated as a CC to the Unspecified code edit code list and four diagnosis codes that were inadvertently omitted from the Unspecified code edit list effective with discharges on or after April 1, 2022.

New FY 2024 Unspecified ICD-10-CM Diagnosis Codes

1. M80.0B9A: Age-related osteoporosis with current pathological fracture, unspecified pelvis, initial encounter for fracture
2. M80.0B9K: Age-related osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with nonunion
3. M80.0B9P: Age-related osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with malunion
4. M80.8B9A: Other osteoporosis with current pathological fracture, unspecified pelvis, initial encounter for fracture
5. M80.8B9K: Other osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with nonunion
6. M80.8B9P: Other osteoporosis with current pathological fracture, unspecified pelvis, subsequent encounter for fracture with malunion
7. L89.103: Pressure ulcer of unspecified part of back, stage 3
8. L89.104: Pressure ulcer of unspecified part of back, stage 4
9. L89.93: Pressure ulcer of unspecified site, stage 3
10. L89.94: Pressure ulcer of unspecified site, stage 4

What Can You Do?