Specific Diagnosis Codes May Reduce Redetermination Request Submissions

Reduce the need to submit a redetermination request. Be sure claims are initially submitted with a specific diagnosis code(s) for the patient's condition; resulting in prompt reimbursement. During reviews, we identified an increase in appeal requests where the claim was submitted using a nonspecific diagnosis code. Example: heart failure, unspecified (I50.9) and cardiomyopathy, unspecified (I42.9). According to the patient's medical records both are correct; however, a more specific diagnosis is necessary as some local policies require specific diagnoses.

When reviewing medical records included within a request, there were several cases in which the added diagnosis codes allowed the claims to reprocess for payment. Example: I25.2 (old myocardial infarction), I50.429 (Chronic combined systolic (congestive) and diastolic (congestive) heart failure)

Specific diagnoses are required for most, if not all, the Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), Local Coverage Articles (LCAs), etc. and do not accept "Unspecified" diagnosis codes.

See the Documentation and Coding that Demonstrates Medical Necessity webpage for additional information.

Last Updated Nov 06, 2019