Medicaid Encounter Data


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I work for a Healthcare Company. We have both a Medicare Advantage Plan and a Medicaid Managed Care Plan. We are being told by our State Medicaid that the ICD-9 rules apply on the line level (24E) of the CMS 1500, not in field 21. It was my understanding that ICD-9 rules were applied in field 21 and field 24E was used to indicate the reason for the services in field 24D.

Here is an example of the issue we are running into:

Per our State Medicaid, the ICD-9 coding guideline rule for "not allowed to be primary" happens at the line level.

For example, manifestation code 362.01 (diabetic retinopathy) must have 249.5x or 250.5x (diabetes) listed before it. But when a member is seeing an eye doctor and they are billing 99214 (office visit) the primary reason for the visit is the 362.01 code, not the 249.5x or 250.5x. Per our State Medicaid the claim will have 249.5x or 250.5x in field 21-1 and 362.01 in field 21-2, and the first diagnosis pointer at the line level should be 249.5x or 250.5x, not 362.01, even though the diabetes is not the primary reason for the visit. Their interpretation of applying these guidelines is that 362.01 is not allowed to be primary there for 249.5x or 250.5x has to be the first diagnosis code referenced in 24E.

My understanding is the diagnosis pointer in 24E for CPT code 99214 should be 362.01 as that is the primary reason for seeing the eye doctor, not the diabetes.

Here is additional information from out IS Security Officer who is responsible for submitting encounter data to our State Medicaid:

Some ICD9 codes are marked as "not allowed to be primary", our question is what is considered the "primary" diagnosis on a claim. The 4010A1 IG and the 5010A1 TR3 both state that the first diagnosis found in LOOP 2300 HI segment (which corresponds to the #1 diagnosis on the HCFA1500) is the "principal" diagnosis on a professional claim. But at the line level LOOP 2400 SV1 segment, there are diagnosis pointers (which also correspond to the paper form) and first one is noted as pointing to the "primary diagnosis for this service line". Does principal or primary diagnosis have separate meanings on a claim?

It's a little confusing and we can't find any documentation that clearly states if the "cannot be primary" is applied to the claim as a whole, or at the individual line level.

Has anyone out there encountered this or does anyone know where I can find documentation that clearly states what level to apply ICD-9 guidelines?



True Blue
Columbia, MO
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I agree with what they are saying. The reason the patient is being seen in your example is for a diabetic opthalmic manifestation which is specifically retinopathy. By listing and linking in the correct order the reason for the visit is correct.