ICD-10 Diagnosis

The U.S. Department of Health and Human Services (HHS) issued a rule finalizing October 1, 2015, as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10, the tenth revision of the International Classification of Diseases.

Claim Form Billing Guidelines

When submitting a data span, the "from" date (not the "to" date) determines whether an ICD-9 or ICD-10 diagnosis code should be on the claim. For claims with "from" dates before October 1, 2015, submit an ICD-9 diagnosis code.

Include the appropriate ICD-10 codes on your submitted paper claim form.

  • Item 21 - Enter patient's diagnosis/condition using highest level of specificity for date of service. Enter diagnoses in priority order. Enter up to 12 diagnosis codes. Relate lines A- L to lines of service in 24E by letter of line. Do not provide narrative description in this field
  • Item 21 - Diagnosis Indicator identifies ICD code set being reported and must be entered in Item 21 of CMS-1500 Claim Form. If indicator field is left blank, claim will be denied as unprocessable on the remittance advice and a new claim must be submitted. Entering number zero, 0, indicates diagnosis is an ICD-10-CM.
  • Item 24E - Enter diagnosis code reference letter as shown in item 21 to relate date of service and procedures performed to primary diagnosis. Enter only one letter per line item. When multiple services are performed, enter primary reference letter for each service. The reference to supply in 24E will be a letter from A-L. If a situation arises where two or more diagnoses are required for a procedure code (e.g., pap smears), provider shall reference only one of diagnoses in item 21. The remaining diagnosis will still be retained as part of the claim for processing considerations.



Last Updated Wed, 02 Nov 2022 14:52:32 +0000