News
ICD-10 National Standard Claim Processing Edits
Date: 10/19/20
Superior HealthPlan periodically reviews its Payer claim edits and associated system configuration to validate full compliance with all Health Insurance Portability and Accountability Act (HIPAA)-required transactions and code sets. These include ICD-10 national standard diagnosis coding requirements.
To ensure all correct coding obligations are fully met, several additional ICD-10 claim processing edits will be implemented in Superior’s claims system effective for service dates on and after November 1, 2020.
Superior does not anticipate an adverse impact to provider claims as result of the revision to ICD-10 coding edits, as applicable national standard coding requirements are a regulatory obligation for practitioners and organizational provider claim billing. However, to ensure all provider claims billing systems are up-to-date to comply with ICD-10 coding requirements, details of the edits planned for November 1, 2020 implementation are included in the table below.
Superior appreciates the cooperation with all claims billing requirements, and appreciates all of our providers continued participation in our network. For any questions about this communication, please contact your Account Manager.
ICD-10 National Standard Claim Processing Edits
ICD-10 | ICD-10 | CLAIM REMITTANCE EXPLANATION (EX) DENIAL CODE | ICD-10 EDIT SOURCE |
|---|---|---|---|
Chemotherapy Only Diagnosis Edit | If chemotherapy service is billed and Z51.11 (encounter for antineoplastic chemotherapy) or Z51.12 (encounter for antineoplastic immunotherapy) is the only diagnosis on the line, the procedure or service is not separately payable. | wd | ICD-10 Manual Coding Requirements |
Chemotherapy Administration Diagnosis Edit | If chemotherapy administration is billed and the Primary, First-Listed or Principal Diagnosis position is NOT Z51.0, Z51.11, or Z51.12, the service will be denied for inappropriate coding. | wd | ICD-10 Manual Coding Requirements |
Primary-Secondary Diagnosis Edit | If a procedure or service is billed with an ICD-10 code designated as a Secondary diagnosis, in the Primary, First-Listed, Principal or Only Diagnosis position, the procedure or service will be denied for inappropriate coding. | wd | ICD-10 Manual Coding Requirements: B General Coding Guidelines - 7. Multiple Coding for a Single Condition |
External Causes Diagnosis Edit | If any procedure or service is billed and the Primary, First-Listed, Principal or Only Diagnosis is one of the ICD-10 codes designated as External Causes of Morbidity, the procedure or service will be denied for inappropriate coding. | wd | ICD-10 Manual Coding Requirements - Section 1 Chapter 20: External Causes of Morbidity (V00 - Y99) |
ICD-10-CM Sequela Code Edit | If any procedure or service is billed and the Primary, First-Listed, Principal or Only Diagnosis is a Sequela diagnosis code (7th character "S"), the procedure or service will be denied for inappropriate coding. | wd | ICD-10 Manual Coding Requirements - B. General Coding Guidelines - 10. Sequela (Late effects) |
Manifestation Code Edit | If any procedure or service is billed and the Primary, First-Listed, Principal or Only Diagnosis is a manifestation code, the procedure or service will be denied for inappropriate coding. | wd | ICD-10 Manual Coding Requirements |
Invalid Diagnosis Edit | If the diagnosis code(s) reported on any service line of the submitted claim is invalid, including: 1) Incomplete: Diagnosis code(s) not reported to the highest level of specificity required; or 2) Inactive: Not a valid diagnosis for the applicable service date; or 3) Non-existent: Diagnosis code does not currently, nor ever existed in the ICD-10 data set, the edit will apply for inappropriately coded diagnosis, and denied. | wd | HIPPA - The Health Insurance Portability and Accountability Act Transaction and Code Set Rule (requires provider to use the medical code set that is valid at the time the service is provided. |
Medicine E/M and Preventive E/M with "Z" Diagnosis Code Edit | If a Medicine Evaluation and Management (E/M) service is billed with a Preventive E/M service and ICD-10 "Z" diagnosis code(s) is the only diagnosis code for the service, the edit will apply for inappropriately coded diagnosis, and denied. | wd | ICD-10 Manual Coding Requirements |
Mutually Exclusive Diagnosis Edit | Mutually exclusive edits are designed to prevent separate payment for procedures that cannot reasonably be performed together based on the code definition or anatomic considerations. Any service line where these diagnosis codes are reported together will have the associated procedure code denied. | wd | ICD-10 Manual Coding Requirements |