Diagnosis Code Requirements

3.4.1.3 - Diagnosis Code Requirements (Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) This section applies to MACs and UPICs, as indicated. ICD-10-CM is used for diagnoses on inpatient discharges and for other services provided on and after the implementation of ICD-10-CM. ICD-9-CM is used for discharges and other services before the implementation of ICD-10-CM. Section 1833(e) of the Act states that no payment should be made “under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person….” MACs and UPICs should require submission of information, in accordance with the requirements below, that they deem necessary to make a claim determination and determine appropriate payment. Some provider types are required to submit diagnosis codes on all claims while other provider types are required to submit diagnosis codes only if such information is required by a LCD. A. Claims Submitted by Physicians or Certain Non-Physician Practitioners Must Contain Diagnosis Codes. Section 1842 (p) (1) of the Act states that for each claim submitted by physicians or certain non-physician practitioners (defined in 1842(b) (18) (C) of the Act) “shall include the appropriate diagnosis code (or codes)….” For claims submitted with invalid, truncated, or missing diagnosis codes, MACs and UPICs shall classify the claim as rejected as unprocessable within the MCS. See the Claims Processing Manuals IOM Pub.100-04. B. Claims Submitted by All Other Provider Types Must Contain Diagnosis Codes if required by a LCD During a service-specific review to address potential abuse or overutilization, MACs and UPICs should require that diagnosis codes be submitted with each claim for the targeted service. The diagnosis information is used to determine if the services are covered and correctly coded. MACs and UPICs should require that ICD diagnosis codes be submitted by all non-physician billers with every claim for a targeted service only if such a requirement appears in a LCD for that service. This outreach shall occur via Web site, bulletin articles, etc. For provider-specific reviews, MACs and UPICs have the discretion to require submission of diagnosis codes to support that the reasonable and necessary criteria has been met on all claims submitted by individual non-physician providers who have been targeted because of unusual billing practices, fraud referrals, etc., even if no LCD exists requiring such codes. For claims submitted with invalid, truncated, or missing diagnosis codes, reviewers shall classify the claim as unable to be processed, and return the claim to the provider (RTP). See the Claims Processing Manual IOM Pub.100-04. C. Requirements for Lab Claims The American Medical Association’s (AMA) 1998 edition of the Current Procedural Terminology (CPT) established three new and one revised Organ and Disease Oriented laboratory panels. Since these panels are composed of clinically relevant groupings of automated multichannel tests there is a general presumption of medical necessity. If there is data or reason to suspect abuse of the panel codes, contractors may review these claims. Should contractors determine the need to develop a LCD for laboratory panel codes the MAC shall develop these policies at the panel code level. In some instances of perceived abuse of the panel codes, the contractors may review the panel and deny component tests on a case-by-case basis or evaluate the need for the component level test.