Wiki HCC /electronic claims 4 diagnosis pointers per line

[Mcuevas]

Hoping someone can weigh in! When submitting professional claims (especially for Preventive visits) We have providers that can address numerous conditions within a single visit, most diagnoses addressed have HCC value I have 2 questions:
1) Will the payer only take the HCC into account if the diagnosis pointer is associated at the line level (cpt) on the claim?
2) Since there are only 4 diagnosis pointers there are times when there may be 12 dx pointers but only 4 attached to the single line, are the remaining 8 not taken into account for HCC?

If this is true is there a way to have the remaining diagnoses (that are addressed and do have M.E.A.T) attributed to our RAF scores at the payer level? Any information and resources would be much appreciated!

 

[smihm]

Check with your software vendor, some have functionality that will submit all 12 diagnosis codes. In addition; some have functionality that will split a claim for you - You can also send in supplemental claims using CPT 99499 or 99080 , some require a penny charge others do not , its payer specific so reach out them to identify which they prefer

 

[TThivierge]

Hello Mcurvas
The first 4 dx is what the some payers review to decide payment or 4 most important problems patient is dealing with. I believe the whole CMS 1500 format is transmitted .However list all dx given per national coding rules (up to 12 dx codes if warranted) those other dx codes are counted when doing annual reporting on pt. s illness and for stats purposes. If have CPT code linked with dx code let us say as dx number 6....it is counted cause paying due to procedure done.
I hope answered your question
Lady T

 

[Mcuevas]

Check with your software vendor, some have functionality that will submit all 12 diagnosis codes. In addition; some have functionality that will split a claim for you - You can also send in supplemental claims using CPT 99499 or 99080 , some require a penny charge others do not , its payer specific so reach out them to identify which they prefer

Thank you for your response, I appreciate it! I have found a Cigna and BCBS document that talks about the 99499. Posting link in case anyone else is interested https://medicareproviders.cigna.com...a-com/docs/claims-12-plus-diagnosis-codes.pdf https://www.floridablue.com/sites/f...ing_Supplemental_and_Additional_Diagnoses.pdf

 

[Mcuevas]

Hello Mcurvas
The first 4 dx is what the some payers review to decide payment or 4 most important problems patient is dealing with. I believe the whole CMS 1500 format is transmitted .However list all dx given per national coding rules (up to 12 dx codes if warranted) those other dx codes are counted when doing annual reporting on pt. s illness and for stats purposes. If have CPT code linked with dx code let us say as dx number 6....it is counted cause paying due to procedure done.
I hope answered your question
Lady T

Good morning, thanks for your reply, if a CPT code is linked to diagnosis #6 then diagnosis #6 is counted, but what if I have diagnosis #7 and #8 on that claim that never link to CPT code at all? Does the payer count #7 and #8 as far as RAF score for that patient, is it still utilized for the annual reporting or since they are not linked to a CPT are they just disregarded? I hope this question makes sense...there has of course been a huge push with HCC/RAF and I just want to make sure our efforts educating and reporting are not futile.

 

[TThivierge]

Hi Mcueva,
Thank you for sharing. Yes most hospital must send annual reports relating to illness to Medicare. So if provider list 12 dx need to add them if applicable to day 's treatment. it is used in the HEDIS and other reports at end of year. Some payer s may use the first 4 dx. and CPT for deciding on reimbursement amounts.
Have a good day!
Lady T

 

[Mcuevas]

Hi Mcueva,
Thank you for sharing. Yes most hospital must send annual reports relating to illness to Medicare. So if provider list 12 dx need to add them if applicable to day 's treatment. it is used in the HEDIS and other reports at end of year. Some payer s may use the first 4 dx. and CPT for deciding on reimbursement amounts.
Have a good day!
Lady T

Thank you!

 

[CBLENNIE]

I work for an insurance carrier and while you can only link 4 DXs to a procedure, we still receive the data on all reported DXs on the claim form. So, if you list 12 DXs, we will have those in our adjudication system and we can see all of these DXs when we are determining the patient's risk adjustment score for our MA & QHP plans. We actually need our providers to report as many DXs as possible/applicable to the patient up the 12 code limit even though you can only link 4 to the a procedure. On facility claims we can actually receive up to 25 DXs on a claim but just the primary DX is associated with the service lines billed.

I would suggest you include as many DXs as possible/appropriate on the claim even though you can only link up to 4 to a service line, the insurance company needs the data if they offer MA or QHP policies for the risk adjustment scoring of the patients covered by these types of plans.