21-317 New ICD-10 Code Editing Update

Date: 05/05/21

Make sure your claim submissions are compliant

Claims received for payment are subject to editing to make sure the claim complies with the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) and the ICD-10-CM Official Guidelines for Coding and Reporting. Participating providers need to adhere to NCCI standards to avoid denial of claims.

To avoid denials based on incorrect coding, be sure to assign the correct diagnosis codes. If you receive a denial determination on the remittance advice (RA) for incorrect coding, refer to the ICD-10 Manual for the code sources.

ICD-10 diagnosis code edits added

Effective July 12, 2021, these three ICD-10 code edits will be used to verify correct coding. The codes will be noted with a denial code on the remittance advice:

EXwd: diagnosis code incorrectly coded per ICD-10 Manual.

Reason description	Edit details
Laterality Diagnosis to Diagnosis Mismatch	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. This edit will monitor laterality mismatch between the diagnosis codes on a claim line.
Laterality Diagnosis to Modifier Mismatch	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. This edit will monitor laterality mismatch between a diagnosis code and the procedure code modifier on a claim line.
Mutually Exclusive Diagnosis Codes	‘Excludes 1’ Notes are located under the applicable 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. This edit will monitor proper billing of diagnosis codes identified in the ‘Excludes 1’ Note.

Reason description

Edit details

Laterality Diagnosis to Diagnosis Mismatch

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. This edit will monitor laterality mismatch between the diagnosis codes on a claim line.

Laterality Diagnosis to Modifier Mismatch

Mutually Exclusive Diagnosis Codes

‘Excludes 1’ Notes are located under the applicable 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. This edit will monitor proper billing of diagnosis codes identified in the ‘Excludes 1’ Note.

Additional information

Providers are encouraged to access California Health & Wellness Plan’s (CHWP’s) provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact CHWP at 877-658-0305.