Use Highly Specific Diagnosis Codes to Prevent Claim Denial

Providers are reminded that they must bill with the most exact diagnosis code possible or claims may deny. According to clinical coverage policy:

Provider(s) shall report the ICD-10-CM and Procedural Coding System (PCS) to the highest level of specificity that supports medical necessity. Provider(s) shall use the current ICD-10 edition and any subsequent editions in effect at the time of service. Provider(s) shall refer to the applicable edition for code description, as it is no longer documented in the policy.

Recently, several diagnosis codes for spinal surgeries have not been carried out to the final character, creating a diagnosis code mismatch and a denial of the claim line. This issue has been resolved and providers who have experienced this issue may now resubmit their claims for reprocessing.