Wiki Regarding Cotivity Edits for Rt & Lt denials

[Donnav]

Hi, We are constantly being denied for right/left H35.3211 & H35.3221. We make the correction with the correct ICD-10 for bilateral though they are treating one eye, but then we have been told that Blue Cross goes by Cotivity Edits and guidelines for correct coding. Does anyone have the information on this for billing Blue Cross?

 

[thomas7331]

Hi, We are constantly being denied for right/left H35.3211 & H35.3221. We make the correction with the correct ICD-10 for bilateral though they are treating one eye, but then we have been told that Blue Cross goes by Cotivity Edits and guidelines for correct coding. Does anyone have the information on this for billing Blue Cross?

Are you saying that you're billing a unilateral diagnosis code that's being denied but then they're paying if you change is to a bilateral code? That doesn't really make sense to me, and I would argue that their edit is set up incorrectly. That does happen - payers don't always use certified coders when they build these edits in their systems so it's not uncommon to see payers do these kinds of things.

But laterality denials are usually for missing modifiers on the CPT codes rather than for the diagnosis code. Are your CPT codes billed with the appropriate modifier that matches the laterality in the ICD-10 code? If not, could you perhaps give a little more detail about what you're billing and what exactly the denial is saying?

 

[Donnav]

Are you saying that you're billing a unilateral diagnosis code that's being denied but then they're paying if you change is to a bilateral code? That doesn't really make sense to me, and I would argue that their edit is set up incorrectly. That does happen - payers don't always use certified coders when they build these edits in their systems so it's not uncommon to see payers do these kinds of things.

But laterality denials are usually for missing modifiers on the CPT codes rather than for the diagnosis code. Are your CPT codes billed with the appropriate modifier that matches the laterality in the ICD-10 code? If not, could you perhaps give a little more detail about what you're billing and what exactly the denial is saying?

Thank you for your response. We are using modifiers correctly, and we are sure we are billing the diagnosis code correctly, however the denial often states, "Claim line denied due to the diagnosis codes incorrectly reported per ICD-10 coding guidelines." We are told there's a Cotivity edits lists, and we need this listing so that we may bill accordingly for future claims.