20-1029 Check Diagnosis Codes to Avoid Claim Denials

Chemotherapy only diagnosis

The malignancy for which the therapy is administered should be assigned as the secondary diagnosis.

Secondary diagnosis

Diagnosis code designated as secondary should be billed in the second position. Applies to both professional and facility claims.

External causes diagnosis

The external causes of morbidity codes must not be sequenced as the first-listed or principal diagnosis. Applies to both professional and facility claims.

Sequela codes

Coding of a Sequela requires reporting of the condition or nature of the Sequela sequenced first, followed by the Sequela code. Applies to both professional and facility claims.

Manifestation codes

If any procedure or service is billed as the Primary, First-Listed, Principal or Only Diagnosis and it is a manifestation code, the procedure code is denied because a manifestation code is a diagnosis of some other underlying disease, not the cause of the disease itself.

Chemotherapy administration diagnosis policy

When a chemotherapy CPT code is present on a professional or facility claim, Z51.11 (Encounter for antineoplastic chemotherapy) or Z51.12 (Encounter for antineoplastic immunotherapy) must be the Primary, First-Listed or Principal diagnosis, unless the chemotherapy or immunotherapy is being administered for a non-neoplastic condition or the Primary, First-Listed or Principal diagnosis code is Z51.0 (Encounter for antineoplastic radiation therapy). Applies to both professional and facility claims.

Invalid diagnosis

The procedure reported with the invalid ICD-10 diagnosis code will have an edit applied for incorrect coding, and the procedure code will be denied.

Incomplete: diagnosis code reported is not coded to the highest level of specificity based on Date of Service (DOS).

Not Active: diagnosis code reported for DOS before its effective date or after the termination date.

Non-Existent: diagnosis code reported that has never been a valid ICD-10 diagnosis code.

This edit only applies to ICD-10 diagnosis codes (DOS October 1, 2015, and later).

The Health Insurance Portability and Accountability Act (HIPPA) - Transaction and Code Set Rule requires the provider to use the medical code set that is valid at the time the service is provided.

E/M with preventive and Z diagnosis code policy

The ICD-10 "Z" codes (Factors Influencing Health Status and Contact with Health Services) allow for the description of encounters for routine examinations (e.g., general check-up, examination for administrative purposes, pre-employment physical). Do not use these codes if the examination for diagnosis of a suspected condition or for treatment purposes; in such cases, the specific diagnosis code (from other chapters) is used. During a routine exam, should a diagnosis or condition be discovered, it should be reported as an additional code.