THCA Notes

Volume XXXI, Number 10
October 2016

Diagnosis Code Requirements for a Professional Claim (837P) Effective October 13, 2016

Per federal regulation, a valid diagnosis code is required on all claims forms submitted for payment, including the 837P professional claims form. A contracted provider delivering medical or health-related services to an individual who has a qualifying medical condition should use a diagnosis code specific to the individual when submitting claims for those services. For dates of service up to and including September 30, 2015, an International Classification of Diseases, Ninth Revision (ICD-9) code is required. For dates of service on or after October 1, 2015, an International Classification of Diseases, Tenth Revision (ICD-10) code is required.

Claims submitted to the Texas Medicaid & Healthcare Partnership (TMHP) through TexMedConnect or Electronic Data Interchange (EDI) without a valid diagnosis code will reject after October 13, 2016.

If a third-party vendor is used for claims submission, it is the responsibility of the provider to notify those vendors about the upcoming changes so software updates can be made if needed.

TexMedConnect

A valid Principal Diagnosis Code must be entered on the first row of the diagnosis table located on the Claim tab. If a Principal Diagnosis Code is not found, an error will occur and the claim will not be accepted.

EDI

A valid Principal Diagnosis Code must be entered on all Long Term Care 837P claims transactions. A validation has been added to verify the diagnosis code is present on batch and interactive transactions. Claim submissions will not be accepted if the validation results in a failure.

Previous communications (Department of Aging and Disability Services Information Letter 15-59) allowed the use of ICD-10 Diagnosis Code Z76.89 (Persons encountering health services in other specified circumstances) when an individual’s service is not directly linked to a specific diagnosis (e.g., Community Attendant Services, Day Activity Health Services, Primary Home Care, Home Delivered Meals, Emergency Response Services, Family Care, Adult Foster Care, and Special Services to Persons with Disabilities). This code remains valid and may be used where appropriate.

For more information, call the LTC Help Desk at 1-800-626-4117, Option 1.