• Up to twelve diagnoses can be reported in item 21 on the CMS-1500 paper claim (02/12)
DIAGNOSIS – ICD
Indicator
Enter 9 for ICD-9 diagnosis codes and 0 for ICD-10
diagnosis codes. The correct code set is determined by date
of service.
Item 21 – Enter the patient’s diagnosis/condition. With the exception of claims submitted by ambulance suppliers (specialty type 59), all physician and nonphysician specialties(i.e., PA, NP, CNS, CRNA) use diagnosis codes to the highest level of specificity for the date of service. Enter the diagnoses in priority order. All arrative diagnoses for nonphysician specialties shall be submitted on an attachment.
Reminder: Do not report ICD-10-CM codes for claims with dates of service prior to implementation of ICD-10-CM, on either the old or revised version of the CMS-1500 claim form. For form version 08/05, report a valid ICD-9-CM code. Enter up to four diagnosis codes. For form version 02/12, it may be appropriate to report either ICD-9-CM or ICD-10-CM codes depending upon the dates of service (i.e., according to the effective dates of the given code set).
• The “ICD Indicator” identifies the ICD code set being reported. Enter the applicable ICD indicator according to the following:
Indicator Code Set
9 ICD-9-CM diagnosis
0 ICD-10-CM diagnosis
Enter the indicator as a single digit between the vertical, dotted lines.
• Do not report both ICD-9-CM and ICD-10-CM codes on the same claim form. If there are services you wish to report that occurred on dates when ICD-9-CM codes were in effect, and others that occurred on dates when ICD-10-CM codes were in effect, then send separate claims such that you report only ICD-9-CM or only ICD-10-CM codes on the claim. (See special considerations for spans of dates below.)
• If you are submitting a claim with a span of dates for a service, use the “from” date to determine which ICD code set to use.
• Enter up to 12 diagnosis codes. Note that this information appears opposite lines with letters A-L. Relate lines A- L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.
• Do not insert a period in the ICD-9-CM or ICD-10-CM code.
General Rules for Diagnosis Codes – ICD codes
The CMS understands that physicians may not always provide suppliers of DMEPOS with the most specific diagnosis code, and may provide only a narrative description. In those cases, suppliers may choose to utilize a variety of sources to determine the most specific diagnosis code to include on the individual line items of the claim. These sources may include, but are not limited to: coding books and resources, contact with physicians or other health professionals, documentation contained in the patient’s medical record, or verbally from the patient’s physician or other healthcare professional.
Beneficiaries are not required to submit diagnosis codes on beneficiary-submitted claims. Beneficiary-submitted claims are filed on Form CMS-1490S. For beneficiary-submitted claims, the A/B MAC (B) must develop the claim to determine a current and valid diagnosis code and may enter the code on the claim.
Inpatient Claim Diagnosis Reporting (Rev. 3081, Issued: 09-26-14, Effective: Upon Implementation of ICD-10,
Implementation: Upon Implementation of ICD-10) On inpatient claims providers must report the principal diagnosis. The principal diagnosis is the condition established after study to be chiefly responsible for the admission. Even
though another diagnosis may be more severe than the principal diagnosis, the principal diagnosis, as defined above, is entered. Entering any other diagnosis may result in incorrect assignment of a Medicare Severity – Diagnosis Related Group (MS-DRG) and an incorrect payment to a hospital under PPS.
The principal diagnosis should not under any circumstances be duplicated as an additional or secondary diagnosis. If the provider reports duplicate diagnoses they are eliminated in Medicare Code Editor (MCE) before GROUPER.
The Admitting Diagnosis Code is required for inpatient hospital claims subject to A/B MAC (A) review. The admitting diagnosis is the condition identified by the physician at the time of the patient’s admission requiring hospitalization. For outpatient bills, the field defined as Patient’s Reason for Visit is not required by Medicare but may be used by providers for nonscheduled visits for outpatient bills.
Outpatient Claim Diagnosis Reporting (Rev. 3081, Issued: 09-26-14, Effective: Upon Implementation of ICD-10, Implementation: Upon Implementation of ICD-10)
For outpatient claims, providers report the full diagnosis code for the diagnosis shown to be chiefly responsible for the outpatient services. For instance, if a patient is seen on an outpatient basis for an evaluation of a symptom (e.g., cough) for which a definitive diagnosis is not made, the symptom is reported. If, during the course of the outpatient evaluation and treatment, a definitive diagnosis is made (e.g., acute bronchitis), the definitive diagnosis is reported. If the patient arrives at the hospital for examination or testing without a referring diagnosis and cannot provide a complaint, symptom, or diagnosis, the hospital reports the encounter code that most accurately reflects the reason for the encounter.
Examples include:
• Z00.00 Encounter for general adult medical examination without abnormal findings
• Z00.01 Encounter for general adult medical examination with abnormal findings
• Z01.10 Encounter for examination of ears and hearing without abnormal findings
• Z01.118 Encounter for examination of ears and hearing with other abnormal findings
For outpatient claims, providers report the full diagnosis codes for up to 24 other diagnoses that coexisted in addition to the diagnosis reported as the principal diagnosis. For instance, if the patient is referred to a hospital for evaluation of hypertension and the medical record also documents diabetes, diabetes is reported as another diagnosis.
Relationship of Diagnosis Codes and Date of Service (Rev. 3081, Issued: 09-26-14, Effective: Upon Implementation of ICD-10, Implementation: Upon Implementation of ICD-10)
Diagnosis codes must be reported based on the date of service (including, when applicable, the date of discharge) on the claim and not the date the claim is prepared or received. A/B MACs (A), (B), (HHH), and DME MACs are required to edit claims on this basis, including providing for annual updates each October.
Shared systems must maintain date parameters for diagnosis editing. Use of actual effective and end dates is required when new diagnosis codes are issued or current codes become obsolete with the annual updates.
The Health Insurance Portability and Accountability Act (HIPAA) requires that medical code sets must be date-of-service compliant. Since ICD diagnosis codes are a medical code set, effective for dates of service on and after October 1, 2004, CMS does not provide any grace period for providers to use in billing discontinued diagnosis codes on Medicare claims. The updated codes are published in the Federal Register each year as part of the Proposed Changes to the Hospital Inpatient Prospective Payment Systems in table 6 and effective each October 1.
All MACs will return claims containing a discontinued diagnosis code as unprocessable. For dates of service beginning October 1, 2004, physicians, practitioners, and suppliers must use the current and valid diagnosis code that is then in effect for the date of service. After the updated codes are published in the Federal Register, CMS places the new, revised and discontinued codes on the ICD-9 or ICD-10 Web site as applicable.
http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html or http://www.cms.gov/Medicare/Coding/ICD10/index.html.
The CMS sends the updated codes to All MACs on an annual basis via a recurring update notification instruction. This is normally released to MACs each June, and contains the new, revised, and discontinued diagnosis codes which are effective for dates of service on and after October 1st.
Coding and Reporting Principles
Claims-Based Reporting Principles Reporting DX for PQRS
• The 2014 Physician Quality Reporting System (PQRS) Measure Specifications contain ICD-9-CM coding and ICD-10-CM coding. Beginning 10/01/2015, the PQRS system will only accept ICD-10-CM codes for analysis.
• A new CMS-1500 claim form (02/12) is available for use to accommodate the new ICD-10-CM coding. CMS will continue to accept the old CMS-1500 claim form (08/05) through March 31, 2014. However, on April 1, 2014, CMS will receive claims on only the revised CMS-1500 claim form (02/12). Claims sent on the old CMS-1500 claim form (08/05) will not be accepted.
• Up to twelve diagnoses can be reported in item 21 on the CMS-1500 paper claim (02/12) (see the 2014 PQRS Implementation Guide) and up to twelve diagnoses can be reported in the header on the electronic claim.
o Only one diagnosis can be linked to each line item.
o PQRS analyzes claims data using ALL diagnoses from the base claim (item 21 of the CMS-1500 or electronic equivalent) and service codes for each individual EP (identified by individual NPI).
o EPs should review ALL diagnosis and encounter codes listed on the claim to make sure they are capturing ALL measures chosen to report and that are applicable to patient’s care.
• All diagnoses reported on the base claim will be included in PQRS analysis, as some measures require reporting more than one diagnosis on a claim.
o For line items containing QDC, only one diagnosis from the base claim should be referenced in the diagnosis pointer field.
o To report a QDC for a measure that requires reporting of multiple diagnoses, enter the reference number in the diagnosis pointer field that corresponds to one of the measure’s diagnoses listed on the base claim. Regardless of the reference number in the diagnosis pointer field, all diagnoses on the claim(s) are considered in PQRS analysis.
• If your billing software limits the number of line items available on a claim, you must add a $0.01 nominal amount to one of the line items on that second claim for a total charge of one penny.
o PQRS analysis will subsequently join claims based on the same beneficiary for the same dateof-service, for the same Taxpayer Identification Number/National Provider Identifier (TIN/NPI) and analyze as one claim.
o Providers should work with their billing software vendor/clearinghouse regarding line limitations for claims to ensure that diagnoses, QDCs, or nominal charge amounts are not dropped.
o In an effort to streamline reporting of QDCs across multiple CMS quality reporting programs, CMS strongly encourages all EPs and practices to begin billing 2014 QDCs with a $0.01 charge. EPs should pursue updating their billing software to accept the $0.01 charge prior to implementing 2014 PQRS. EPs and practices will need to work with their billing software or EHR vendor to ensure this capability is activated.
