24-1214 Bill Correct Primary Diagnosis on Facility Claims to Avoid Payment Delays

Date: 11/21/24

Follow CMS and ICD-10-CM correct coding guidelines to ensure compliance

Effective February 4, 2025, new edits will be applied on outpatient and inpatient facility claim payments to ensure compliance with national billing guidelines supported by the Centers for Medicare & Medicaid Services (CMS) and ICD-10-CM.

Claims edits

Inappropriate primary diagnosis – Claim edits will cause a denial when billed with an unacceptable primary/principal diagnosis, manifestation diagnosis or sequela diagnosis on an outpatient or inpatient facility claim. Providers will need to submit a corrected claim with a primary diagnosis code that is in accordance with coding and CMS guidelines.

Find the correct principal diagnosis

• Use the ICD-10-CM guidelines to determine the correct primary diagnosis code that describes the current illness or injury.
• Unaccepted principal diagnosis is a coding convention in ICD-10-CM. Those identified codes do not describe a current illness or injury, but a circumstance which influences a patient’s health status.

What is a sequela code

Per the ICD-10-CM manual guidelines –

• A sequela code (the seventh character "S") is used for complications or conditions that arise as a direct result of an injury.
  
• Sequela is the late effect of an injury, such as pain or scar formation after
  a burn.

Resources

• ICD-10-CM Official Guidelines for Coding and Reporting FY 2024 (Centers for Disease Control and Prevention)
• Medicare Claims Processing (CMS)

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, Community Supports (CS) Providers, Enhanced Care Management (ECM) Providers, and Behavioral Health Providers.

This information applies to Medi-Cal in Fresno, Kings and Madera counties.