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Do not report E Codes as primary Diagnosis - New Instructions


CMS provides new instructions to return as unprocessable claims submitted on the Form CMS-1500 where an ICD-9-CM "E" Code (external causes of injury and poisoning) is reported as the first/principal diagnosis on the claim.

CR7700 will bring the policy for handling form CMS-1500 claims into alignment with the policy for handling claims initially submitted in electronic format. The ICD-9-CM code set prohibits an “E” code from being reported as principal diagnosis (first-listed) on a claim. This guidance also applies to V00-Y99 (external causes of morbidity) equivalent ICD-10 CM diagnosis codes. Therefore, if an “E” code or V00-Y99 range ICD-10 CM diagnosis code is the first listed diagnosis code on the CMS-1500, the claim would not conform to the ICD-9-CM code set and electronic transmission of the electronic claim to a Coordination of Benefits Agreement (COBA) trading partner would not be Health Insurance Portability and Accountability Act (HIPAA) compliant.

Claims initially submitted as electronic claims will, effective April 1, 2012, be rejected in accordance with an edit established by CMS CR7596 when the principal (first) diagnosis code presented in the diagnosis code field is an “E” code or, effective with the implementation of ICD-10, when the principal (first) diagnosis is a code within the code range V00-Y99 of the ICD-10- CM code set. This procedure will prevent those non-HIPAA compliant claims from being adjudicated and then transmitted to the Coordination of Benefits Contractor (COBC) for COBA crossover purposes.

Be aware of the following:

• For claims received via form CMS-1500 on or after April January 1, 2013, Medicare contractors will return as unprocessable claims for items or services where a diagnosis code is required and the diagnosis code reported in the Number 1 field of Item 21 of the Form CMS-1500 is an ICD-9-CM “E” code (external causes of injury and poisoning) or, upon ICD-10 implementation, an ICD-10 CM code within the code range of V00-Y99

• Reprocessed/adjustment claims failing these edits will be denied.

• Claims returned or denied as a result of these edits will show remittance advice remarks code message MA63 (Missing/incomplete/invalid principal diagnosis) and claim adjustment reason code 16 (Claim/service lacks information which is needed for adjudication).

Reference: http://cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7700.pdf

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