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Back  RFI # 168: 837I Loop 2300, segment HI02

Formal vs. Informal Help Informal Formal

Submitter

Sandra Kahlandt

Description

In this segment Nebraska Medicaid requires BJ for outpatient claims to indicate Admit Diagnosis when there are room charges. When claims are sent with ZZ in HI02-1 the data in HI02-2 is not processed by Nebraska Medicaid. These claims are denied. Is this an appropriate use of the BJ qualifier? This is the only way Nebraska Medicaid currently picks up the diagnosis code.

Submitter Assigned Keywords

BJ, admiting diagnosis, patient reason for visit

Response

It is inappropriate and not permissible for the receiver to require the usage of BJ for outpatient claims. The guide very clearly requires qualifier 'ZZ' for unscheduled outpatient visits. The principal diagnosis
is required with the exception of claims with a Bill Type of 14X, 4XX or 5XX.

Recommendation

Admitting diagnosis (BJ qualifier) can only be required by a receiver for inpatient claims. A receiver who mandates the use of BJ qualifier to report any other diagnosis or requires an admit diagnosis on all claims is in violation of the guide.
Submission 12/13/2004
Status Date 4/1/2005
Status F - Final
Primary References
Document 004010x096
Section3
Page228
Set ID837I
Table2
Loop2300
Segment Position231
Segment IDHI
Element Position01
Industry NamePatient Reason for Visit