Health Information Management

Q&A: Modifiers and ICD-10-CM

HIM-HIPAA Insider, January 18, 2011

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Q: Since laterality will be identified in ICD-10-CM diagnosis codes, will we still need to use HCPCS II/CPT® modifiers such as -RT (right side) or -LT (left side) or -50 (bilateral procedure)?

A: This is a great question. Even though the addition of laterality (right/left) to the ICD-10-CM diagnosis codes adds specificity not seen in ICD-9-CM, the concept of unilateral/bilateral in a diagnosis code isn’t new. So I think it is helpful to explore how both appear in ICD-9-CM versus ICD-10-CM and their relation to CPT codes.
 
For instance, the ICD-9-CM diagnosis code for an initial bilateral inguinal hernia (without gangrene or obstruction) would be 550.92. The fifth digit identifies whether the hernia was unilateral or bilateral, as well as whether it was identified as recurrent.
 
The ICD-10-CM code for this same diagnosis is K40.20 (Bilateral inguinal hernia, without obstruction/gangrene, not specified as recurrent) and as you can see it is the same.
 
Repairs in CPT for this type of inguinal hernia (in a patient 5 years and older and stated as reducible) would be either 49505 (open) or 49650 (laparoscopic). The CPT guidelines identify in a parenthetical note that it would be appropriate to append modifier -50 identifying a bilateral procedure when a physician performs it. The diagnosis code 550.92 already identified that the hernia was bilateral but it is still necessary to append the modifier.
 
As illustrated above the concept of unilateral/bilateral codes currently exists in ICD-9-CM, but bhe concept of identifying right side versus left side is new in ICD-10-CM.
 
For example, coders will assign one ICD-9-CM code, 813.23, for the initial encounter for a traumatic closed fracture of the shaft of the radius and ulna. The combination code does identify that the fracture was of both bones in the forearm but it does not state if the fracture was on the right or left side, so if a patient suffered bilateral closed fractures of the shaft of the radius and ulna coders would only report ICD-9-CM code 813.23 one time.
 
The ICD-9-CM Official Guidelines for Coding and Reporting states, “Each unique ICD-9-CM diagnosis code may be reported only once for an encounter. This applies to bilateral conditions or two different conditions classified to the same ICD-9-CM diagnosis code.”
 
However, if a patient suffers traumatic bilateral fractures of these same bones coders will report four codes in ICD-10-CM:
  • S52.301A (Unspecified fracture of shaft of radius, right radius)
  • S52.302A (Unspecified fracture of shaft of radius, left radius)
  • S52.201A (Unspecified fracture of shaft of radius, right ulna)
  • S52.202A (Unspecified fracture of shaft of radius, left ulna)
ICD-10-CM does not include a combination code to identify fractures of both the radius and ulna but rather coders report each separately.
 
Regarding CPT codes for repairs of fractures, for a closed reduction without manipulation of the bilateral radial and ulnar shaft fractures, coders would report CPT code 25560. To identify that the provider performed this procedure bilaterally, coders would report either 25560-RT and 25560-LT or 25560-50 (depending on payer requirements) because the CPT code does not inherently state that the procedure is bilateral in the code description.
 
Even though ICD-10-CM’s added specificity is evident in codes for right/left sides (e.g., for fractures), the concept of unilateral/bilateral has existed for many years (e.g., for hernias). The instructional notes in CPT do indicate it is still necessary to append modifiers to CPT codes when a physician performs a procedure on only the right or left side, as well as when the physician performs the procedure bilaterally—even though some diagnosis codes already state this information.
 
Editor’s note: Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding at HCPro Inc., in Danvers, MA, answered this question for JustCoding.



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