Changelog

What you will see

Automated claim validation (ClaimCleaner) checks the side of service on each line: the RT and LT modifiers, and the side in each diagnosis code. Validation now changes the right or left side only when the line documents that side, with one exception below. The sides that a line documents are the sides of its diagnosis codes and of its RT, LT or 50 modifier.

• No undocumented side. Validation does not add an RT or LT modifier, or a right or left diagnosis code, for a side that the line does not document.
• No reversed side. Validation does not change a documented right side to left, a left side to right, or a sided code to an unspecified code.
• Both sides on one line. When a line documents both sides, validation does not choose one side. It can only make the line bilateral: modifier 50, or the bilateral code of the same condition.
• Same condition only. When validation adds the side to a diagnosis code with an unspecified side, the new code must describe the same condition. For example, a dislocation code does not become a subluxation code.
• Every diagnosis stays on the line. When validation corrects the side of two or more diagnoses on one line, each diagnosis gets its own correction and keeps its place in the list. A secondary diagnosis does not move to the first-listed position.
• No retired codes. Validation does not add a diagnosis code that is not valid for the date of service. For example, it does not add M54.5 (low back pain), which is not billable for dates of service after September 30, 2021.
• One exception. Validation reads the side of a diagnosis code from the code set. A few bilateral codes, for example M17.0 (bilateral primary osteoarthritis of knee), do not carry a side there yet. Validation reads such a code as a code with no side, so it can still add that code to a line that documents one side or no side, or put it in place of a right or left code of the same condition.

For example: an interventional radiology claim bills a thrombectomy of the right leg veins (37187) with I82.411 and I82.421 (right femoral and right iliac vein thrombosis) and no side modifier. Validation adds RT and keeps both right-side codes.

Nerve block lines and the side of the surgery

• Validation no longer changes the side of the diagnoses on the main anesthesia line to match the RT or LT modifier of a nerve block line. The main anesthesia line keeps the side that the surgery documentation states.
• When a nerve block line carries RT or LT and the surgery documentation states the other side, validation reports the difference. The autocoder does not show this report to a coder yet, so no alert appears for it. In a sample of 2,336 recent fully automated anesthesia cases, the difference occurred on 1 case.

Alert changes

• No alert is added or removed.
• ClaimCleaner Added ICD Code, ClaimCleaner Added Anesthesia Modifier and ClaimCleaner Added Surgical Modifier can appear less often, because validation makes fewer side changes. On radiology claims, ClaimCleaner-Added Contralateral Diagnosis Stripped (Undocumented) can also appear less often.

What to look out for

• Expect fewer side changes from validation on anesthesia and radiology claims.
• When the record does not document a side, the line keeps the side as coded. Add the side from the record when your payer requires it.
• On a line that documents one side or no side, check a bilateral diagnosis that validation added, for example M17.0.
• On a claim with a nerve block, compare the side of the block line with the side of the surgery. The autocoder does not ask about a difference yet.
• Nothing changes in your configuration.

What you will see

ICD-10 requires combination codes when certain conditions appear together. Hypertension with chronic kidney disease codes as I12.0 or I12.9, not as I10 plus the kidney code alone. Hypertension with heart failure codes as I11.0. Type 2 diabetes with chronic kidney disease codes as E11.22.

Before this change, the autocoder applied these combinations most of the time but not every time. Some claims went out with I10 and N18.x listed separately.

Now a rules engine checks every claim after the AI review. If a standalone code and its related condition both remain, the engine replaces them with the correct combination code. The stage code (N18.x) and the heart failure code (I50.x) stay on the claim, as ICD-10 requires. The combination code is sequenced before the stage and heart failure codes, in the order ICD-10 instructs.

Hypertension with both heart failure and chronic kidney disease uses the I13 family. When all three conditions appear together, the claim codes as I13.0 or I13.2 (the code follows the kidney disease stage). When an I13 code is on the claim, the lesser hypertension codes drop off: I10, I11.x, and I12.x. A partial combination already coded as I11.x or I12.x is upgraded to I13.x when the record also documents the missing condition. You will see I13 codes the autocoder never produced before, and you will see I11 or I12 codes disappear when the full combination applies. Both outcomes follow the ICD-10-CM instructions. A separate new alert, "Diagnosis Validation Returned No Result", names a claim where the diagnosis review step returned nothing at all.

What to look out for

• Claims where this correction fired carry the informational note "Combination Diagnosis Code Applied". No action is needed. The note is an audit trail.
• You will no longer see I10 next to N18.x, I10 next to I50.x, or E11.9 next to N18.x on the same claim.
• If the record shows the conditions are unrelated, flag the claim to your coding team. The presumption of a causal link comes from ICD-10-CM rules and applies unless the provider documents otherwise.

Our coding experts reviewed the autocoder and directed the rules below. No action is required on your side.

Spine anesthesia 00670 follows the overall extent of the operation. The autocoder selects 00670 when the operation uses instrumentation, or covers three or more vertebral bodies, or covers two or more disc levels. The levels do not need to be next to each other.

Abdominal cases route by the operative field. The autocoder selects between upper abdomen 00790 and lower abdomen 00840 from the field the record documents, not from the name of the procedure alone. A colon case routes to 00790 unless the work is only on the sigmoid or the rectum. An exploratory laparotomy (49000) routes to 00790.

Three diagnosis rules changed. A symptom code or a site pain code is dropped when it is part of a documented condition. A personal history code is dropped when the autocoder codes the current condition. A status code never ranks first on the claim.

What to look out for: spine and abdominal code selection will look different on affected cases. Diagnosis lists will be shorter and ordered differently. Both changes follow the expert review.

The screening diagnosis stays on a combined upper and lower GI claim. On a combined endoscopy case coded as 00813, both procedures need a supporting diagnosis. The autocoder now keeps the screening code Z12.11 on the claim as the second ranked diagnosis instead of dropping it. The order is fixed: the upper GI diagnosis ranks first, the screening code ranks second, and the colon findings (for example K63.5 or K62.1) rank third.

A new alert names a claim where the screening code is dropped anyway. The diagnosis validation step, or the limit on how many diagnoses a line can carry, can still remove the code. When that happens the claim carries the informational alert "Screening Diagnosis Dropped from Combined GI Claim", and the alert names what was removed.

The PT modifier rule for 00813 is described in the July anesthesia update.

What to look out for: on combined GI claims, expect Z12.11 to stay on the claim in second position. If you see the dropped screening alert, check whether the screening diagnosis belongs back on the claim before you release it.

O80 is coded only when a delivery happened during this stay. O80 reports an encounter for a full term uncomplicated delivery. A labor only case that carried O80 could be billed as a delivery again when the patient came back. The autocoder now requires a documented delivery in this stay. It also requires an outcome of delivery code (Z37) as a secondary diagnosis. It blocks O80 whenever any pregnancy complication is coded.

External cause codes are suppressed on anesthesia claims. Codes from the V, W, X and Y chapters no longer appear on these claims.

A condition documented as a past event is coded as history. A prior heart attack or a prior stroke gets a history code, not a code for a current condition.

An abdominal case documented above the navel routes to 00790. The autocoder selects the upper abdomen code when the record documents an incision or an exploration above the umbilicus. Anesthesia billing follows the operative field, not only the name of the procedure.

What to look out for: a labor only encounter no longer carries a delivery diagnosis. Confirm that the record states the delivery when you expect O80. An abdominal case documented above the navel carries 00790 and the base units of that code.

Z86.010 is not billable, and the autocoder no longer uses it. That code became non billable on 2024-10-01 and was split into five character codes. The autocoder now selects Z86.0101 for a history of adenomatous or serrated polyps, which is the most common surveillance case. It selects Z86.0100 when the record does not document the type of polyp. It selects Z86.0102 for a history of hyperplastic polyps only. It selects Z86.0109 for another documented history of colon polyps.

A documented family history of polyps now codes to Z83.71. The autocoder used the family history code for digestive cancer before this change. A family history of polyps is not a family history of cancer, and Z83.71 is the correct code.

What to look out for: lower endoscopy claims with a documented polyp history no longer carry the parent code Z86.010. Review any claim that you already submitted with Z86.010, because the payer rejects that line. Correct it to the five character code that the record supports, then resubmit.