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Billing with only 4 diagnosis

  1. #1
    Question Billing with only 4 diagnosis
    Medical Coding Books
    Our software currently has a glitch were only 4 dx can be entered for claims. Sometimes the Doc has 5 or 6 dx documented in the chart, but we cannot input those for billing the claim. Only the top four. Is this a big problem? Is it considered fraudulant to not report the other codes? I know only 4 codes appear on a claim anyway, but I am getting mixed answers.

    I just want to know that if an audit happens, I would be penalized for not have the 5th or 6th code on the billing side of things.

    Please help!

  2. #2
    Columbia, MO
    the 5010 allows for 12 and the payer does see all 12. The only problem will be if you need to link a procedure to dx 5,6,7,8,9,10,11,or 12.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Concord, NC or Rochester, NY
    The payor may see all 12 but I am not aware of any payor that will use them. In fact, ask Medicare how many they actually use and the answer will often come out to "1".

  4. #4
    I have the opposite problem with my software--it still allows me to enter up to 12 dx per CPT code even though only the first 4 will be transmitted on the claim! The 5010 standards do allow 12 diagnoses to be submitted with each claim, but only a maximum of 4 diagnoses can point to any given CPT code. Under the 4010 standards, we could send up to 8 dx per CPT code, and when I asked a coder at our software vendor why there was a reduction in 5010, I was told it was in preparation for ICD-10 where greater specificity within each dx code will mean a case can be described in fewer diagnoses. That may be true for some specialties, but I think there will still be plenty of cases where the doctors will document more than 4 codes.

  5. #5
    Columbia, MO
    You have always been limited to linking only 4 dc codes per line item hcpcs/cot code. You can list 12 and link 4 any 4. You use to be able to list 8 but still only link 4.

    Debra A. Mitchell, MSPH, CPC-H

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