Wiki CMS Form 1500

[krystalmyates]

I'm a relatively new auditor and I have a client who is asking what to do should they have more than the 12 diagnoses on the form 1500. They are a chiropractic office, and the answer is so clear in my head but I am doing a terrible job conveying it to her. We've had three conversations about it and I still haven't said it clearly to her. So as plainly as possible, can somebody answer this question for me? (I'm not putting what I've told her a. to ensure I am answering correctly and b. to ensure I am getting it in your own words)

 

[LLovett]

Why do they need more than 12 Dx? That seems excessive for a chiro claim. The patient may have a laundry list of issues the provider has to consider but they should only be reporting the issues they are actually treating on their claims.

If you have multiple procedure codes that have different Dx supporting them you would need to split the claim if there isn't enough room for all procedures to be linked to their primary Dx.


Dx 1-12 on claim 1 with procedures 1, 2, and 3.
Dx 13, 14 on claim 2 with procedure 4

Generally this was more of an issue when you are dealing with multiple vaccines, but I haven't really run into this since the claim form expanded to 12 Dx spots.

Hope this helps,

Laura, CPC, CPMA, CPC-I, CANPC, CEMC

 

[Cynthia Hughes]

You might try advising that the charges must be split to two claims based on which services correspond with each diagnosis code. If the provider feels that more than 12 diagnoses represent the reason for a single service, only the first 12 diagnosis codes would be reported in conjunction with that service. I would also recommend reviewing the diagnoses to be sure that symptoms integral to a condition are not being separately reported and that only conditions that impacted evaluation and management/treatment are being reported.

 

[krystalmyates]

Thank you both! Laura, I've told her essentially the same thing - but I'm going to try your wording. I agree that even 12 diagnoses is excessive under most circumstances. And yes, I'm waiting for her to send me a sample to be sure they are being reported correctly. I hope that it is just worry over ICD-10 that is bringing these questions on.

I really appreciate the answers. You've given me much needed confidence!