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Use of invalid or incorrect diagnosis codes


PCG has found that there has been an increase in ongoing rejections from Medicaid due to providers utilizing invalid or expired ICD-10 codes.  

What Providers Need to Know:

Medicaid requires an active, full ICD10 code be utilized in the submission of claims

  • Some diagnosis codes now have an additional digit that indicates specificity (i.e., using R63.30, R63.31, R63.32, R63.39 vs diagnosis with less specificity R63.3 – it is missing the last specificity digit) 
  • The “P” category diagnosis codes:  According to the Knowledgebase Article on prematurity, “Diagnosis code(s) for extreme prematurity have limitations on use. Medicaid follows national coding guidelines pertaining to age edits in eMedNY for diagnosis codes. If a child was determined eligible for the EIP based on a diagnosis of extreme prematurity and this is the diagnosis included in the billing claim for services, Medicaid and possibly other Third-Party Payors may only reimburse claims for a limited time (up to the child reaching 2 years old).”  The perinatal codes are typically only for the time before birth through the 28th day following the birth.  The only time the codes may continue to be used throughout life is if the condition is still present.  
  • The diagnosis utilized on the IFSP may not be appropriate for the services being billed.  Providers should enter the diagnosis that fits what the child is being seen for when entering claims.  Diagnosis are used in conjunction with procedure information from claims to support the medical necessity determination for the service(s) rendered and sometimes to determine the appropriate reimbursement.  

Adding diagnosis to the 2nd field in NYEIS, leaving primary field blank

  • In addition, it has come to our attention that providers may be adding the diagnosis code in NYEIS to the second position when there is no diagnosis in the primary position.  This causes the claims to error in EI Billing due to missing diagnosis code.  

PCG will be reaching out to providers via phone and email who have rejections reported by Medicaid to fix claims in the system advising the root cause.  It is imperative that appropriate ICD10 codes be entered when the services are initially billed to avoid recurrent Medicaid rejections.  

Article ID: 477, Created On: 4/14/2023, Modified: 4/14/2023

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