Medlearn
Matters…Information for Medicare
Providers
(Issued by the Centers for
Medicare & Medicaid
Services)
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Invalid
Diagnosis Code Editing - Second Phase
Provider Types Affected
All physicians, providers, and suppliers who bill
Medicare carriers, including Durable Medical Equipment
Regional Carriers (DMERCs)
Provider Action Needed
Impact to You
New edits will be added to the Medicare claims processing
systems to prevent acceptance of inbound claims with
invalid diagnosis codes.
What You Need to Know
Diagnosis
codes must always be valid on the date that the service
was provided. Medicare systems will reject claims with
diagnosis codes that were not valid on the date of
service.
What You Need to Do
As Medicare
strengthens its edit processes to detect and reject
claims with invalid diagnosis codes, ensure that your
billing staff know the rules for diagnosis codes and that
they submit diagnosis codes that are in compliance with
HIPAA.
Background
To edit diagnosis
codes accurately for validity, Medicare systems will
apply date range edits to ensure that diagnosis codes are
valid for the period of time for which they are reported
on claims sent to Medicare. These edits will apply
whether or not Medicare actually uses the reported
diagnosis code in its claims processing.
HIPAA rules require that Medicare makes sure that such
codes are HIPAA-compliant, especially because these codes
are passed on to other payers under Medicare’s
Coordination of Benefits processes. To be compliant, the
diagnosis code must be valid on the date for which it is
reported. These policy changes include validation of
diagnosis codes on the National Council for Prescription
Drug Program (NCPDP) claims and on 837 professional
claims.
Additional Information
Additional information regarding this topic can be found
in Transmittal 86 (CR 3050). The official instruction
issued to your carrier regarding this change may be found
by going to:
http://www.cms.hhs.gov/Transmittals/
From that Web page, look for CR 3260 in the CR NUM
column on the right, and click on the file for that
CR.
Disclaimer
Medlearn Matters articles are
prepared as a service to the public and are not intended
to grant rights or impose obligations. Medlearn Matters
articles may contain references or links to statutes,
regulations, or other policy materials. The information
provided is only intended to be a general summary. It is
not intended to take the place of either the written law
or regulations. We encourage readers to review the
specific statutes, regulations, and other interpretive
materials for a full and accurate statement of their
contents.
For more information, visit the Medlearn Matters Web
page at: http://www.cms.hhs.gov/MedlearnMattersArticles/.
Related Change Request (CR) #:
3260
Medlearn Matters Number: MM3260
Related CR Release Date: October 22,
2004
Related CR Transmittal #: 326
Effective Date: April1,
2005
Implementation Date: April 4, 2005
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