Billing diagnosis on a claim line but not associating with a line on HCFA claim.

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Murray, UT
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All,
does anyone know if there are any coding guidelines about billing diagnosis codes on a HCFA claim but not associating a diagnosis on a claim line?
 

CBLENNIE

Contributor
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Meridian, ID
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I work for an insurance company which sells Medicare Advantage plans, which are we receive payment from CMS based on the beneficiaries risk adjustment score and we need all of the members diagnoses in order for the score to be calculated. Therefore, we require our in-network providers to submit all diagnoses applicable to a patient. It is quite common to see all 12 diagnosis fields populated in box 21 of a HCFA, even though you can only list up to 4 diagnosis codes to a given line item on the claim. If only 1 diagnosis code applies to a service being billed, but the patient has additional conditions/diagnoses, you would bill the procedure/service and only link diagnosis A, the primary diagnosis for the visit, to the line item. For example:

Patient has diagnoses listed in fields A & B in box 21 of the HCFA claim form; however, the only condition addressed during the office visit is E11.649, you would only list A in the Diagnosis Pointer field E of box 24.

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Does this make sense and help? If not please don't hesitate to message me directly and I'll try to assist you further.
 

SharonCollachi

True Blue
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Clovis, CA
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There are billing programs that will not let you list a diagnosis on a claim if there is no pointer for it, as the diagnoses are entered at the claim line level. If it's not on a claim line, it's not on the HCFA (FOR ME).
 

csperoni

True Blue
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Selden
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The 2 most recent programs I've used will not let you put a dx on the HCFA if it is not linked to at least procedure.
 
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Oviedo, FL
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There are billing programs that will not let you list a diagnosis on a claim if there is no pointer for it, as the diagnoses are entered at the claim line level. If it's not on a claim line, it's not on the HCFA (FOR ME).
Our ACO advised us that we could add cpt code 99080 with a zero charge to the claim and attached the patient conditions/diagnosis to report those add'l codes.
 
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