Primary Diagnosis Code Required on Claims

Primary Diagnosis Code Required on Claims

With the implementation of the new HIPAA 5010 ASC X12 version, the transaction requirement for a primary diagnosis code was changed from situational to required for 837 claims transactions. Effective April 1, 2012, this billing requirement will also apply to both Indiana Health Coverage Programs (IHCP) paper and Web interChange claim submissions.

This change affects even providers that are currently exempt from submitting a diagnosis code specific to Transportation, Waiver, and Durable Medical Equipment (DME) services. Transportation and Waiver providers should bill diagnosis code 7999 as the primary diagnosis code for claim submissions where the actual diagnosis is not known. For DME providers, the primary diagnosis code will need to be obtained from the physician that ordered the DME supplies or equipment.

If a claim is submitted on Web interChange without a primary diagnosis code indicated, an error message will display stating, "Primary diagnosis is required". Paper claims missing the primary diagnosis code will be denied for edit 258 - Primary Diagnosis code missing.