What Is Preventing Your Electronic Claims from Being Accepted? Institutional Electronic Data Interchange (EDI) regularly identifies the most frequent errors on electronically submitted claims. These edits are ANSI 837 Implementation Guide edits that prevent claims from being accepted into FISS. You would see these errors on your Inbound Reject Report. Analysis of claims submitted from December 20, 2005 to March 20, 2006 shows the top ten errors to be as follows: OTH DIAG CODE INVALID LOOP: 2300 SEGMENT: HI ELEMENT: 02 QUALIFIER: BF PRIN DIAG CODE INVALID LOOP: 2300 SEGMENT: HI ELEMENT: 02 QUALIFIER: BK ADMIT DIAG CODE INVALID LOOP: 2300 SEGMENT: HI ELEMENT: 02 QUALIFIER: BJ RESOLUTION: THE PHYSICIAN SHOULD CODE THE ICD-9-CM CODE THAT PROVIDES THE HIGHEST DEGREE OF ACCURACY AND COMPLETENESS. IN THE CONTEXT OF ICD-9-CM CODING, THE “HIGHEST DEGREE OF SPECIFICITY” REFERS TO ASSIGNING THE MOST PRECISE ICD-9-CM CODE THAT MOST FULLY EXPLAINS THE NARRATIVE DESCRIPTION OF THE SYMPTOM OR DIAGNOSIS. CONCERNING LEVEL OF SPECIFICITY, ICD-9-CM CODES CONTAIN EITHER 3, 4, OR 5-DIGITS. IF A 3-DIGIT CODE HAS 4-DIGIT CODES WHICH FURTHER DESCRIBE IT, THEN THE 3-DIGIT CODE IS NOT ACCEPTABLE FOR CLAIM SUBMISSION. IF A 4-DIGIT CODE HAS 5-DIGIT CODES WHICH FURTHER DESCRIBE IT, THEN THE 4-DIGIT CODE IS NOT ACCEPTABLE FOR CLAIM SUBMISSION. UPDATED ICD-9-CM CODES ARE PUBLISHED IN THE FEDERAL REGISTER IN APRIL/MAY OF EACH YEAR AS PART OF THE PROPOSED CHANGES TO THE HOSPITAL INPATIENT PROSPECTIVE PAYMENT SYSTEM, AND ARE EFFECTIVE EACH OCTOBER FIRST. PHYSICIANS, PRACTITIONERS, AND SUPPLIERS MUST USE THE CURRENT AND VALID DIAGNOSIS CODE THAT IS IN EFFECT BEGINNING OCTOBER 1, 2005. AFTER THE ICD-9-CM CODES ARE PUBLISHED IN THE FEDERAL REGISTER, CMS PLACES THE NEW, REVISED, AND DISCONTINUED CODES ON THE FOLLOWING WEB SITE: HTTP://WWW.CMS.HHS.GOV/MEDLEARN/ICD9CODE.ASP PROVIDERS WITH AN OMNIPRO LOGON SHOULD USE INQUIRIES/ICD-9 IN FISS TO DETERMINE IF THE DIAGNOSIS YOU INTEND TO USE IS VALID BEFORE SUBMITTING THE CLAIM. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * PAYMNT SRCE CD NOT = MA LOOP: 2000B SEGMENT: SBR ELEMENT: 09 QUALIFIER: RESOLUTION: THE VALUE ‘MA’ IS REQUIRED FOR MEDICARE PART A. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * DEPENDENT TO SUBSCRIBER IS NOT ALLOWED LOOP: 2000C SEGMENT: PAT ELEMENT: 01 QUALIFIER: RESOLUTION: THE ENCOMPASSING LOOP (2000C/HL SEGMENT) IS NEVER USED FOR MEDICARE. THE SUBSCRIBER AND THE PATIENT ARE ALWAYS THE SAME AND REPORTED IN THE 2000B LOOP (SUBSCRIBER LEVEL). * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ADJ AMT INVALID/MISSING DATA LOOP: 2320 SEGMENT: CAS ELEMENT: 03 QUALIFIER: RESOLUTION: THIS IS A SITUATIONAL SEGMENT. SUBMITTERS USE THIS CAS SEGMENT TO REPORT PRIOR PAYERS CLAIM LEVEL ADJUSTMENTS. THIS DATA ELEMENT HOLDS THE MONETARY AMOUNT OF THE ADJUSTMENT. IF THIS SEGMENT IS SENT, THEN THIS DATA ELEMENT IS REQUIRED. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ADJ QUANTITY INVALID/MISSING DATA LOOP: 2320 SEGMENT: CAS ELEMENT: 07 QUALIFIER: RESOLUTION: THIS IS A SITUATIONAL SEGMENT. SUBMITTERS USE THIS CAS SEGMENT TO REPORT PRIOR PAYERS CLAIM LEVEL ADJUSTMENTS. THIS DATA ELEMENT HOLDS THE UNITS OF SERVICE BEING ADJUSTED AND MAY BE REQUIRED DEPENDING ON THE CLAIM ADJUSTMENT REASON CODE FOUND IN CAS 05 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * PAT REASON FOR VISIT IS INVALID LOOP: 2300 SEGMENT: HI ELEMENT: 02 QUALIFIER: ZZ RESOLUTION: THE PHYSICIAN SHOULD CODE THE ICD-9-CM CODE THAT PROVIDES THE HIGHEST DEGREE OF ACCURACY AND COMPLETENESS. IN THE CONTEXT OF ICD-9-CM CODING, THE “HIGHEST DEGREE OF SPECIFICITY” REFERS TO ASSIGNING THE MOST PRECISE ICD-9-CM CODE THAT MOST FULLY EXPLAINS THE NARRATIVE DESCRIPTION OF THE SYMPTOM OR DIAGNOSIS. CONCERNING LEVEL OF SPECIFICITY, ICD-9-CM CODES CONTAIN EITHER 3, 4, OR 5-DIGITS. IF A 3-DIGIT CODE HAS 4-DIGIT CODES WHICH FURTHER DESCRIBE IT, THEN THE 3-DIGIT CODE IS NOT ACCEPTABLE FOR CLAIM SUBMISSION. IF A 4-DIGIT CODE HAS 5-DIGIT CODES WHICH FURTHER DESCRIBE IT, THEN THE 4-DIGIT CODE IS NOT ACCEPTABLE FOR CLAIM SUBMISSION. UPDATED ICD-9-CM CODES ARE PUBLISHED IN THE FEDERAL REGISTER IN APRIL/MAY OF EACH YEAR AS PART OF THE PROPOSED CHANGES TO THE HOSPITAL INPATIENT PROSPECTIVE PAYMENT SYSTEM, AND ARE EFFECTIVE EACH OCTOBER FIRST. PHYSICIANS, PRACTITIONERS, AND SUPPLIERS MUST USE THE CURRENT AND VALID DIAGNOSIS CODE THAT IS IN EFFECT BEGINNING OCTOBER 1, 2005. AFTER THE ICD-9-CM CODES ARE PUBLISHED IN THE FEDERAL REGISTER, CMS PLACES THE NEW, REVISED, AND DISCONTINUED CODES ON THE FOLLOWING WEB SITE: HTTP://WWW.CMS.HHS.GOV/MEDLEARN/ICD9CODE.ASP PROVIDERS WITH AN OMNIPRO LOGON SHOULD USE INQUIRIES/ICD-9 IN FISS TO DETERMINE IF THE DIAGNOSIS YOU INTEND TO USE IS VALID BEFORE SUBMITTING THE CLAIM. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * TAXONOMY CODE IS INVALID LOOP: 2310A SEGMENT: PRV ELEMENT: 03 QUALIFIER: RESOLUTION: BEGINNING WITH ANSI ASC 837 VERSION 4010 A1, PRV SEGMENT IN BILLING/PAY-TO PROVIDER SPECIALTY INFORMATION LOOP IS OPTIONAL IN INSTITUTIONAL CLAIMS. IF NOT REQUIRED FOR YOUR BILLING SITUATION, ELIMINATE THE SEGMENT COMPLETELY. IF USED, ENSURE THAT YOU ARE USING A VALID TAXONOMY CODE. A LIST OF VALID TAXONOMY CODES AS WELL AS OTHER CODE SETS CAN BE OBTAINED FROM WWW.WPC-EDI.COM * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ATTN PHYS UPIN REQUIRED LOOP: 2310A SEGMENT: REF ELEMENT: 02 QUALIFIER: RESOLUTION: ALL CLAIMS THAT LIST A PHYSICIAN WHO HAS RENDERED SERVICES MUST INCLUDE THE PHYSICIAN’S UPIN. IF A PHYSICIAN DOES NOT HAVE HIS OR HER OWN UPIN AND IS IN THE PROCESS OF OBTAINING ONE, CMS ALLOWS THE USE OF “OTH000” AS A “SPECIAL USE” UPIN.“ NPP000” IS NOT A VALID UPIN. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Watch the Medicare News Update for our monthly analysis of IG errors, and visit our Web site at www.empiremedicare.com where we will be posting our findings in the future to help you improve the acceptance rate of your claim submissions. |
. THE UPDATED ICD-9-CM DIAGNOSIS CODES CAN ALSO BE VIEWED AT THE NATIONAL CENTER FOR HEALTH STATISTICS (NCHS) WEB SITE AT:
