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Back  RFI # 617: Diagnosis Code requirement

Formal vs. Informal Help Informal Formal


Ethel Williams


In the 4010A1 Implementation guide for Institutional claims it states that HI Principal, Admitting, E-Code and Patient Reason For Visit Diagnosis Information is "Required on all claims and encounters except claims for Religious Non-medical claims (Bill Types 4XX and 5XX) and hospital other (Bill Types 14X)."

In the UB04, this condition is not included. The UB04 manual is a bit vague on this. It states that for UB92, ‘Completion of this field is required for Medicare billing except for religious nonmedical healthcare institutions. It does not say anything for UB04.

Please advise as to whether the DX should be required regardless of the bill type? Does the 837 Addenda Implemenation guide take precedence for this situation?

Submitter Assigned Keywords

HI information Codes - Prinipal/Admitting DX codes for Institutional claims


This issue is explicitly addressed in guide 004010X096A1. Sections 1.1.1 and 1.1.2 both state that this guide is the authority. Trading partner agreements must not "Modify the definition, condition, or use of a data element or segment in the standard Implementation Guide" and "Institutional transaction cannot be implemented except as described in this Implementation Guide."

Therefore, this guide establishes the requirements, not the UB04 or UB92. Diagnosis Codes can only be required when the bill type is NOT 4XX, 5XX or 14X. However, they can be sent in those situations at the sender's discretion.
Submission 12/13/2007
Status Date 12/14/2007
Status F - Final
Primary References
Document 004010x096A1
Set IDX096A1