This document provides coding and billing guidelines for the proper reporting of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes. BCBSND has seen an increase in Payment Integrity denials due to inappropriate ICD-10-CM codes submitted on claims. This guideline is being issued to provide additional education to our provider community to promote correct coding.
Coding & Billing Guidelines
Blue Cross Blue Shield of North Dakota (BCBSND) follows the ICD-10-CM Official Guidelines for Coding and Reporting, developed through a collaboration of The Centers for Medicare & Medicaid Services (CMS), the National Center for Health Statistics (NCHS), and the Department of Health and Human Services (DHHS), which provides a clear direction on the coding and sequencing of diagnosis codes.
Diagnosis codes must be coded to the highest level of specificity for the condition reported, based upon the degree of clinical detail documented in the medical record for the encounter. Diagnoses not coded to the highest level of specificity may cause a claim line or entire claim to deny requiring a claim correction be submitted.
Inappropriate Primary Diagnosis
According to the ICD-10-CM Official Guidelines, inappropriate primary diagnosis codes include:
- Manifestation codes – Should never be the sole diagnosis on a claim. The underlying disease should be coded first followed by the manifestation code. In most cases the manifestation codes will include the verbiage, “in diseases classified elsewhere.”
- Code First - “Code first” notes occur with certain codes that are not specifically manifestation codes but may be due to an underlying cause. When a “code first” note is present which is caused by an underlying condition, the underlying condition is to be sequenced first, if known.
- Secondary Diagnosis codes – “Use additional code” indicate that secondary diagnosis code(s) should be used however the secondary diagnosis will never be primary.
- Sequela codes - A sequela encounter uses the letter “S” in the 7th position and indicates a late effect that occurs after the acute phase of the injury or illness has passed. When reporting sequela(e) two codes must be reported. The ICD-10-CM manual stipulates that the residual should be coded first, followed by the healed illness/injury.
- External cause codes - V, W, X or Y codes which describe the circumstance causing an injury, not the nature of the injury, and therefore should not be used as the primary diagnosis.
- “Z” Codes - Factors Influencing Health Status and Contact with Health Services are represented as “Z” codes. These codes provide details on the reason for presenting for healthcare services, including but not limited to encounters for routine exams. Depending upon the reason for the encounter, they may be factors Influencing Health Status and Contact with Health Services are represented as “Z” codes. These codes provide details on the reason for presenting for healthcare services, including but not limited to encounters for routine exams. Depending upon the reason for the encounter, they may be primary or secondary codes. An additional diagnosis code should be used if a diagnosis or condition is discovered during a routine exam. This additional diagnosis code will need to be included on the claim.
Laterality Specific Codes
ICD-10-CM codes which specify laterality must be coded to the highest level of specificity. Claims billed using “unspecified” laterality codes may result in a denial. Additionally, claims will be denied when an anatomical modifier conflicts with the diagnosis provided on the claim.
Within the ICD-10-CM Manual, there are two types of excludes notes. Excludes1 stands for “not coded here” which means the diagnosis codes should never be billed together. Excludes2 represents “not included here” meaning the diagnosis codes can be billed together when appropriate.
When billing on the UB-04 Claim Form a “Principal” diagnosis is required. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
BCBSND adopts the CMS published list of codes which are considered unacceptable as a principal diagnosis for an inpatient facility claim. These codes describe a circumstance which influences an individual’s health status but not a current illness or injury, or codes that are not specific manifestations but may be due to an underlying cause.
Inpatient Claims - BCBSND requires the principal diagnosis as well as the admitting diagnosis on the UB-04 Claim Form.
Limitations & Exclusions
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits, and medical necessity
- Mandated or legislative required criteria will always supersede.