Author: Clinical Policy and Programs
The implementation of ICD-10-CM allows specificity for accurate coding, resulting in greater justification of medical necessity. A provider’s documentation must include details to completely depict the nature of a beneficiary’s diagnosis and procedures performed. Comprehensive documentation ensures that the encounter can be coded to the highest level of certainty known and allows for proper claim reimbursement.
For codes which provide detailed specificity of anatomical laterality, the use of unspecified codes is not justified. The ICD-10-CM diagnosis code H02539 – eyelid retraction unspecified eye, unspecified lid is not acceptable because in the medical record the provider should be able to identify the specific eye and eyelid. ICD-10-CM diagnosis code H02531 – eyelid retraction right upper eyelid indicates laterality, is specific and has a higher level of certainty.
For further information, refer to the 2018 ICD-10-CM Professional for Physicians, ICD-10-CM Official Guidelines for Coding and Reporting 2018 and the Centers for Medicare & Medicaid Services (CMS) ICD-10-CM/PCS Frequently Asked Questions website.
Providers with questions can contact the CSRA Call Center at 1-800-688-6696 or NCTracksprovider@nctracks.com.
Clinical Policy and Programs
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