Wiki More than 4 diagnosis are not being captured

[cmcevoy]

Our patients are complex and most of the encounters have more than 4 diagnosis/line. In result, we are constantly coming up with missing opportunities for HCC codes. The HCC codes are being reported by the providers but are not being captured because the line has more than 4 diagnosis associated. How do you solve this problem besides submitting medical records to payors? Is there a way around this?

 

[amyjph]

Here is an example: https://www.bluecrossnc.com/provide...additional-claim-chronic-and-acute-conditions

https://medicareproviders.cigna.com/static/medicareproviders-cigna-com/docs/claims-12-plus-diagnosis-codes.pdf

https://www.floridablue.com/sites/floridablue.com/files/docs/Update_on_Submitting_Supplemental_and_Additional_Diagnoses.pdf

You can check with the payer and also, your EHR vendor or clearinghouse should be able to help.

 

[cmcevoy]

Thanks for your response Amy. Do you know if this process can be automated or is this more like a manual submission? Other words, would the new claim drop automatically with the additional dx if more than 4 dx were associated? I will consult with our EHR vendor but I am curious to know if anyone is doing this automatically.

 

[TThivierge]

Hi Cmcevoy
It should not be dropping to only 4 dx codes for inpatient status. Inpatient UB90 format can take at least 20 dx codes. I believe the problem is how the inpatient billing form is linking the same as the outpt. billing CMS1500 format. Check with the clearinghouse or the payer could have it linked improperly. I know you can do manual submission with direct claim submission but that is tedious ! Most EHR and insurance payer set up should be doing automatic transmission once it is set up .

 

[amyjph]

Thanks for your response Amy. Do you know if this process can be automated or is this more like a manual submission? Other words, would the new claim drop automatically with the additional dx if more than 4 dx were associated? I will consult with our EHR vendor but I am curious to know if anyone is doing this automatically.

I think with some EHR they would have the capability to automate it if more than 12 are entered in the charge screen. I have not done it myself.

 

[cmcevoy]

Hi Cmcevoy
It should not be dropping to only 4 dx codes for inpatient status. Inpatient UB90 format can take at least 20 dx codes. I believe the problem is how the inpatient billing form is linking the same as the outpt. billing CMS1500 format. Check with the clearinghouse or the payer could have it linked improperly. I know you can do manual submission with direct claim submission but that is tedious ! Most EHR and insurance payer set up should be doing automatic transmission once it is set up .

We billed electronically but I am referring to outpatient, billing for office visits on 1500 format.

 

[TThivierge]

Hi
This maybe the trend with payers to only look at first 4 dx codes on the CMS 1500 claim even though it takes 8 dx codes. I have heard before insurance payers clearinghouse only look at first 4 dx codes. I think to get more dx codes reviewed you might have to talk to your EHR or clearinghouse. But it might be a fee to view more dx codes when transmitting instead of only 4.
Good Luck
Lady T.

 

[cmcevoy]

Hi
This maybe the trend with payers to only look at first 4 dx codes on the CMS 1500 claim even though it takes 8 dx codes. I have heard before insurance payers clearinghouse only look at first 4 dx codes. I think to get more dx codes reviewed you might have to talk to your EHR or clearinghouse. But it might be a fee to view more dx codes when transmitting instead of only 4.
Good Luck
Lady T.

Ok, we will contact the clearinghouse, thanks for your advice.