March 4, 2021
For claim process dates April 4, 2021 and after, new edits will be implemented to address correct of diagnosis and procedure codes submitted on facility claims and professional claims.
Facility Claim Edits:
- Unacceptable principal diagnosis codes which describe the circumstances influencing an individual’s health status but isn’t a current illness or injury. These codes are based on Medicare code edits (MCE). Unacceptable diagnosis codes can be identified in an ICD-10 CM diagnosis codebook with a notation as unacceptable principal diagnosis.
For example:
Z56.3 – Stressful work schedule
C80.2 – Malignant neoplasm associated with transplanted organ
- Manifestation codes can’t be billed as a principal diagnosis code. They describe the manifestation of an underlying disease but not the disease itself. There will usually be a coding note indicating to code for another condition before the manifestation code. Manifestation codes can be identified in an ICD-10 CM diagnosis codebook as well.
For example:
I76 – Septic arterial embolism (code first underlying infection)
D63.8 – Anemia in other chronic disease classified elsewhere (code first underlying disease)
- Invalid inpatient admitting diagnosis codes are diagnosis codes that are billed either before the effective date of the diagnosis code or after the termination of the diagnosis code.
Professional Claim Edits:
- Implantable cardiac interrogation devices/cardiovascular physiologic monitor systems (codes 93297, 93298 and G2066), per code description, can’t be billed more than once each 30 days. An edit will trigger when the frequency of billing of these codes is less than 30 days.
- Complex care management codes (99487-99489) and chronic care management codes (99490-99491, 99439), per new parenthetical coding guidelines added for 2021, can’t be billed in the same calendar month as End Stage Renal Service (ESRD) codes 90951-90970. These complex and chronic care management codes are considered part of the ESRD services and can’t be billed in the same calendar month.
- Review the new parenthetical note added to both the care management and ESRD codes in the 2021 CPT codebook.
For further information, review the ICD-10 CM diagnosis codebooks to identify diagnosis categories and review the new parenthetical coding guidelines added to the critical and chronic management care codes for 2021.
Check your electronic medical records/electronic health record (EMR/EHR) applications to see if any settings can address unacceptable principal diagnosis codes, manifestation codes, and invalid inpatient admitting diagnosis codes as part of diagnosis selection.