Basic Coding Guidelines

Current ICD-10-CM codes, CPT codes, HCPCS codes, and modifiers in effect on the date of service are required on all Health Net claims.

These codes should be used in basic accordance with the publishers' stated guidelines. Three major publications - the American Medical Association's Current Procedural Terminology (CPT-4) code book, the Centers for Medicare and Medicaid Services' (CMS') Healthcare Common Procedural Coding System (HCPCS) code book and the International Classification of Diseases (ICD-10-CM) - represent the basic standard of service code documentation and reference required by Health Net.

Valid ICD-10-CM diagnosis codes are required on all claims. The first diagnosis on the claim form is reserved for the primary diagnosis. Up to four diagnoses may be reported.

Code each diagnosis to the highest level of specificity (4th or 7th digit when available).

Valid AMA CPT-4 and Level II HCPCS procedure codes are required on all claims. A three-month grace period for submitting deleted codes is allowed. After three months, deleted codes are denied.

Procedure codes should be chosen based on the publishers' definitions and be appropriate for the age and gender of the member.

Procedure code modifiers are to be used only when the service meets the definition of the modifier and are to be linked only to procedure codes intended for their use.

If a deleted code and its current replacement code are submitted on the same date of service, the last code submitted is denied as a duplicate.

Health Net does not require documentation at the time of claim submission; however, in the event the claim is audited, documentation may be required.

Supporting Sources

• AMA CPT Book
• CMS National Policy
• HIPAA