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Back  RFI # 1615: Diagnosis codes in Prof 837

Formal vs. Informal Help Informal Formal

Submitter

Chip Evelsizer

Description

In an auto accident injuries to the patient may be severe impacting numerous parts of the body requiring providers to include numerous distinct diagnosis codes (Dx) on a single bill to justify treatment. In some jurisdictions, the adjudication/payment decision may be impacted by the Dx codes included/excluded on the bill. Also, jurisdiction and federal mandates require reporting of known Dx values.

CMS1500 paper bills sometimes include 12+ distinct Dx values. In the 5010 Prof TR3, when 12+ Dx values are necessary, where should additional values be sent? Providers are sending Dx values in an NTE segment in the 837. Is this compliant with the TR3? If compliant, which NTE segment should be used (Claim/Line Note)? If Claim Note is used, must the qualifier be DGN? If Line Note is used, what qualifier must be used? Should the Dx contain a decimal? Should the NTE02 also contain a Dx qualifier? If 12+ Dx codes are sent, how does this impact pointers? If the line level NTE is used, does this constitute a pointer?

Submitter Assigned Keywords

diagnosis Dx dgn nte

Response

There is no segment specifically designated to send additional diagnosis codes that exceed the maximum allowed in the single repeat of the HI – Health Care Diagnosis Code segment of the 5010 Professional TR3.

A provider may use the NTE segments whenever, in their judgment the information is needed to substantiate the medical treatment and the delivery of this information is not supported elsewhere in the TR3. The NTE segment used is dependent upon whether the information applies to the entire claim or to a specific service line.

At the claim level NTE, if the information is related to a Diagnosis Description, then the qualifier DGN should be used. At the line level NTE, if the information is not related to Goals, Rehabilitation Potential, or Discharge Plans, then the qualifier ADD should be used.

The NTE segments are silent in regards to the formatting of the information. It’s left to the discretion of the provider.

The TR3 does not support diagnosis pointers that exceed the 12 diagnoses submitted in the HI segment. If the line level NTE segment is used, the information in the NTE relates only to the related line item.
Submission 6/22/2012
Status Date 8/31/2012
Status F - Final
Primary References
Document 005010X222
Section2.4
Set ID837
Industry NameDiagnosis Code