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How to submit a claim with more than 12 diagnosis.

Revi Posted Mon 01st of April, 2019 10:48:38 AM
We need to submit claims with more than 12 diagnosis for reporting purposes. Is there away to submit a claim with more than 12 diagnosis? We have already had the claim split on the clearinghouse end, however they split the claim with a duplicate E&M code, which causes issues on the insurance side.
SuperCoder Answered Tue 02nd of April, 2019 03:57:00 AM

As per CMS, form 1500 (medical claim form used by individual doctors & practice, nurses, and professionals including therapists, chiropractors and outpatient clinics) modified to support up to 12 diagnosis codes per claim (while maintaining the limit to four diagnosis code pointers) in an effort to reduce paper and electronic claims from splitting. Any codes exceeding those limits would split the 837 into 2 (two) claims and paper claims into 3 (three). Increasing the total of supported diagnosis codes on the claim format helped to reduce the amount of claims splitting and this helped alleviate costs for both payers and practices. However, 12 (twelve) diagnosis codes are allowed per claim, only four diagnosis codes are allowed per line item (each individual procedure code). Means, only 4 (four) diagnosis codes can pointed (connected) to each procedure to per claim line.

Here is the example, on CMS 1500 form, box 21, where more than 4 diagnosis codes on a claim is vital to documenting the full extent of a patient’s illness. While there are 12 places holders for diagnoses, only a maximum of 4 is allowed for each single procedure performed. This means there can be up to 8 floating diagnoses that are captured as current diagnoses of the patient, that may be additional diagnoses related to the charges (but unable to be pointed to them as 4 are already pointing to the procedure), or they may be additional diagnoses related to the MDM (Medical Decision Making) of the visit as current other comorbidities. On the other hand, if the insurance is showing the duplicate E&M claim after split, then make them aware about the concern. Although, there is no impact on the reimbursement when filling the claim with less diagnosis.

Hope this helps!

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