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This Memo dates from 1996, but many practices overlook its importance. The bottom line is that any claim submitted with an ICD code that is non-specific will be automatically returned for reprocessing. For the primary care physician, this is a HUGE issue.
For example, a claim submitted with the category diagnosis of Diabetes Mellitus-250 would be returned since there are 5th digit subcategory codes available to use. If an office bills $50 for the visit, then spends $8 to resubmit a claim, that office in effect has just lost 16% of potential revenue. Flash Code prevents this from happening by using easy to follow green lights (go to more specific codes) and red lights (stop and pick your code) when finding ICD codes and uses ICD code specificity as a filter when validating codes.
-Karlen Bailie M.D.
Owner DBL Enterprises
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Health Care Financing Administration Memorandum
Department Of Health & Human Services
Subject: Returning Claims for Truncated Diagnosis Coding--ACTION
To: Associate Regional Administrators For Medicare
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In a prior memorandum dated August 14, 1995, we had stated that beginning October 1, 1995, carriers not currently doing so would return as unprocessable assigned claims for physician services billed with truncated diagnosis coding. Because the "return as unprocessable" instruction for Part B claims has been delayed until April 1, 1996, returning claims for truncated coding is also
delayed.
Assigned claims for physician services submitted with truncated diagnosis coding should be "returned as unprocessable" beginning July 1, 1996. Please share this information with carriers and standard systems maintainers in your region. If a claim is submitted with only one line item which points to a truncated diagnosis code, that claim should be returned. If a claim contains multiple line items, only those line items that point to a truncated diagnosis code will be returned as unprocessable. Returning a claim as unprocessable does not mean that every claim will be physically returned. The term "return as unprocessable" will be used to refer to the many processes used by Medicare carriers to notify physicians that a claim or specific lines within a claim cannot be processed (refer to MCM 3005.1). For carriers not already doing so, only unassigned services furnished by a physician which reference a truncated diagnosis code will be developed.
Between now and July 1, 1996, carriers are to focus on educating physicians concerning the importance of accurate ICD-9-CM coding. Educational efforts should emphasize the importance for physicians to use the Most recent version of the ICD-9-CM coding book and make physicians aware through regularly scheduled bulletins, seminars and other routine communications that assigned service with truncated diagnosis codes will be returned as unprocessable beginning July 1, 1996. Please emphasize that physicians should not add or substitute numbers where they do not already exist in the coding scheme. For example, there are some legitimate 3 digit ICD-9 codes that do not have a fourth or fifth digit. Physician offices should not add zeros or nines to these codes. The code selected should accurately describe a patient's illness or disease and be listed in the latest ICD-9 edition. Some examples of the most frequently truncated diagnosis codes are:
-- (Diabetes Mellitus) 250 requires 5 digits. The fourth digit must be 0 through 9; the fifth digit must be 0 through 3
-- (Osteoarthrosis and allied disorders) 715 requires 5 digits. The fourth digit must be 0,1,2,3,8, or 9; the fifth digit must be 0 through 9
-- In the case of hypertensive disease, malignant essential hypertension is coded as 401.0 and benign essential hypertension is coded as 401.1. There is no fifth digit available for essential hypertension in the current coding system. Benign hypertensive heart disease without congestive heart failure is coded as 402.10 and benign hypertensive heart disease with congestive heart failure is coded as 402.11.
-- (Malignant neoplasm of prostate) 185; do not add a zero, 185.0 is incorrect
-- (Chronic Renal failure) 496; do not add a zero. 496.0 is incorrect
The use of fictitious diagnosis code XX000, as explained in MCM 4020.3(D)(2), should be discontinued for use on unassigned claims. A valid ICD-9 code will be required as of July 1, 1996 (i.e., develop for complete diagnosis codes on unassigned services furnished by physicians, do not plug in the fictitious code XX000).
The Medicare Carriers Manual, Section 4020 is being updated to reflect this change in the handling of truncated diagnosis codes.
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