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# of Dx codes per CPT code - Does the 5010 transaction change

J

j.berkshire

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Does the 5010 transaction change the number of diagnosis codes that can be reported for each CPT code on a claim? Currently, a claim can link up to four diagnosis codes to each CPT code. I don't see this addressed in any of the ICD-10 or 5010 transaction publications. Thanks,
 
5010 will allow for unlimited reporting of a diagnosis code on electronic claims but not on paper. Of course, payers may limit how many they process. There are many benefits of 5010 but most will only be realized in the electronic world.
 
Rhonda,
Thanks for your response. In the 5010 electronic version, if an unlimited number of diagnosis codes are submitted, is the diagnosis "pointer" field, 24E from the paper format, still limited to pointing to 1-4 of all the diagnosis codes for each CPT code? What happens to the diagnosis codes beyond 4?
 
here is an excerpt from the information available through the AMA on the 5010:
• What is the difference with 5010?:
– Increases the field size for ICD codes from 5 bytes to 7 bytes bytes
– Adds a one‐digit version indicator to the ICD code to indicate version 9 vs. 10 vs.10
– Increases the number of diagnosis codes allowed on a claim from 8 to 12
- Data used for the same purposes in different transactions is represented consistently across all transactions, which will decrease confusion. For example, a patient is defined the same in all transactions. -The instructions for reporting “situational data” were reformatted to specifically define when or when not to send the data. Situational data is data that may or may not be required to be reported based on whether or not certain conditions are met. For example, reporting a patient’s middle name or middle initial is required when it is needed to identify the individual. If the data is not required to be reported based on the condition statement, then the receiver (e.g., payer) cannot require it be sent
- Data fields that accommodated multiple types of data have been separated so that distinct data is reported in each field. For example, 4010 had a field for reporting either the referral number or prior authorization number, which caused confusion as to which number was being reported. In 5010, these fields have been separated to their own distinct fields.


So while I am not arguing, this states there will be a maximum of 12 dx codes allowed per claim, not unlimited. I am still looking for the publication that stated you can still link only 4. The information available regarding the 5010 is very thin so I would love to have the reference that states unlimited dx codes may be submitted.
 
Last edited:
Ok here it is from the AMA fact sheet 4:
The maximum number of diagnosis codes that can be reported on a claim was increased from
eight to twelve. Although twelve diagnosis codes can be reported at the claim level, only four
codes can be pointed to, or linked to, a specific service at the service line level. So if a patient
has twelve diagnoses and you perform a service that relates to five diagnoses, you can only point
to four of them when billing for that service line.
 
Ok here it is from the AMA fact sheet 4:
The maximum number of diagnosis codes that can be reported on a claim was increased from
eight to twelve. Although twelve diagnosis codes can be reported at the claim level, only four
codes can be pointed to, or linked to, a specific service at the service line level. So if a patient
has twelve diagnoses and you perform a service that relates to five diagnoses, you can only point
to four of them when billing for that service line.
 
I understand that we can now report more diagnoses codes in total but I'm look for some guidance or ideas on where to find these answers:

1. Are there any guidelines on how/when to increase your number of diagnoses? I understand the concept of reporting what is most relevant to the service provided, but just wondering why/when we should increase?

2. All sources I can find relating to the number of diagnoses codes are from 2011 - is it still true that the total was increased to 12 but still only 4 diagnoses per CPT code? I thought I heard something about 25 CPT and 25 ICD9 codes being accepted? (That seems huge to me..)

3. If number 2 is true, that only 4 per CPT code still, that could be why I can't find anything on when you should adding more diagnoses codes to your claim... Because while we can now report more total dx codes, we are still only reporting 4 per CPT code?

Thanks!
 
Inpatient only 25 dx codes

I have heard 5010 only will support 12 dx codes for outpatient. 5010I will support 25 for inpatient. If someone has evidence to support something other than this, please show it.

CMS Manual System Department of Health &Human Services (DHHS)
Pub 100
-
04 Medicare Claims Processing Centers for Medicare &Medicaid Services (CMS)
Transmittal 2028
Date:
AUGUST 13. 2010
SUBJECT: 5010 Implementation
--
Processing Additional International Classification of Diseases, 9th
Revision
-
I. SUMMARY OF CHANGES:
With the implementation of the
5010 837I transaction in January 2011, the number of ICD 9
CM diagnosis and procedure codes are being expanded from 9 and 6 to 25 and 25. This will require changes to the Inpatient Prospective Payment System (IPPS), Inpatient Psychiatric Facility (IPF) PPS and the Skilled Nursing Facility (SNF) Pricers and the Fiscal Intermediary Standard System (FISS) interface to these Pricers. In addition, the FISS interface to the Grouper and MCE will be changed.
 
Can anyone provide a direct link to this information on professional diagnosis and pointers for 5010/837 listed above? Been searching on CMS and can not find specific details regarding it.

Thank you,
 
Is it still only 4 codes per a claim line now that we have to use the new version 02/12 claim forms?
 
99354 code

hi Rhonda, I have a question for you

we use the 3M program to code and we have EHM, we are HMO and we give service to Medicare and Medicaid patients
the questions is,
3M accept only 12 diagnosis, if the phycian document more than 12, which CPT code we may use in the second line for complete the list of the diagnosis documented, could be 99354 code???????, or we could finish the complete dx with category II code 1159F and 1160F when the Doctor review all medication in this visit ??????? , example:
99213- 496,427.31,440.0,272.4,244.9,311,723.1,715.00,293.80,331,83etc
?????? - #,#,#,#,#

those ???????= which CPT (99354 or Cat II codes)
thanks: confused:
 
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