All Providers Important ICD-10 Edit and EOB Information

New Edits and EOBs for ICD-10

The following new edits will be in place when the use of ICD-10 begins on October 1, 2015:

1.  Claims containing ICD-10 diagnosis codes in the following range as the primary or only diagnosis will deny. V00 – Y99 are codes indicating “External Causes of Morbidity”. These codes are to be used secondary to another diagnosis code, indicating the event or circumstances causing the injury or other adverse condition.

EOB 01748 - PRIMARY OR PRINCIPAL DIAGNOSIS NOT ALLOWED. PLEASE VERIFY AND ENTER THE CORRECT DIAGNOSIS CODE AND SUBMIT AS A NEW CLAIM

2.  ICD-10 codes must be submitted with the required number of digits; codes that are not will deny for “insufficient digits.”

EOB 01757 - DIAGNOSIS NON-SPECIFIC. PLEASE VERIFY AND ENTER THE CORRECT DIAGNOSIS CODE AND SUBMIT AS A NEW CLAIM

3.  Claims will deny if they contain a diagnosis code that is not covered.

EOB 01754 - DIAGNOSIS NOT COVERED. PLEASE VERIFY AND ENTER THE CORRECT DIAGNOSIS CODE AND SUBMIT AS A NEW CLAIM

Providers with claims that fail these edits can correct the diagnosis and resubmit the claim. To see what ICD-10 diagnosis codes correspond to ICD-9 codes, refer to the NCTracks ICD-10 Crosswalk.

 

New Edits for ICD Qualifier

There are also two new edits and associated EOBs related to the ICD Qualifier that is required on all X12 837 claim transactions beginning October 1. A claim can contain either ICD-9 or ICD-10 codes, but not both. The ICD Qualifier is used to designate which version of ICD codes is used on the claim. The new edits are triggered when the version of ICD code (9 vs 10) submitted on the claim does not match the version designated in the ICD Qualifier:

Edit 02670 - ICD VERSION INVALID (Drug Claims)

Edit/EOB 02671 - ICD VERSION INVALID FOR DATE OF SERVICE (All other claim types)

Correct the ICD Qualifier or the ICD code(s) on the claim, whichever is in error, and resubmit the claim. For more information about the ICD Qualifier, refer to the July 2 announcement on the NCTracks Provider Portal.

 

Existing Edits Affected by ICD-10

In addition, there are many existing edits and associated EOBs that will be triggered by errors related to ICD-10. These edits can be posted for various reasons, so it may not be immediately apparent that the cause of the failed edit is ICD-10 related. Following are details about some of the most common existing edits affected by ICD-10.

 

Diagnosis Not Valid

For example, Edit 00190 for Diagnosis Not Valid with EOB 00027: DIAGNOSIS CODE MISSING OR INVALID. VERIFY AND ENTER THE CORRECT DIAGNOSIS CODE AND SUBMIT AS A NEW CLAIM will post under several circumstances related to ICD-10:

·   A claim with an ICD-9 diagnosis for a date of service on or after October 1

·   A claim with an ICD-10 diagnosis for a date of service before October 1

·   An invalid code, either ICD-9 or ICD-10, regardless of date of service

·   Any end-dated diagnosis code

Other diagnosis code related edits and EOBs that may post with an ICD-10 error include:

 

Edit 00191 & Edit 00192	EOB 00019 - PRIMARY AND/OR SECONDARY DIAGNOSIS CODE INVALID. VERIFY, CORRECT, AND SUBMIT AS A NEW DAY CLAIM
Edit 00194	EOB 00012 - DIAGNOSIS OR SERVICE INVALID FOR RECIPIENT SEX

 

Providers with claims that fail one of these edits should ensure the claim reflects a valid diagnosis code based on the date of service and resubmit the claim.

 

Procedure Invalid for Diagnosis

Also, there are several EOBs that may post to claims that fail edits for Procedure Invalid for Diagnosis. These edits are triggered when the diagnosis code billed is not appropriate for the service rendered. Possible edits and EOBs in this category include:

 

Edit 00153	EOB 00082 - SERVICE IS NOT CONSISTENT WITH/OR NOT COVERED FOR THIS DIAGNOSIS/OR DESCRIPTION DOES NOT MATCH DIAGNOSIS
Edit 00441	EOB 00049 - MEDICAL NECESSITY IS NOT APPARENT
Edit 00442	EOB 02099 - EFFECTIVE 10/01/2011 THE MEDICAL EYE EXAM CODE BILLED IS NOT ALLOWED WHEN THE ONLY DIAGNOSIS CODE(S) ON THE CLAIM INDICATE THE SERVICE WAS PERFORMED FOR REFRACTION
Edit 04506	EOB 00082 - SERVICE IS NOT CONSISTENT WITH/OR NOT COVERED FOR THIS DIAGNOSIS/OR DESCRIPTION DOES NOT MATCH DIAGNOSIS
Edit 04507	EOB 07729 - DIAGNOSIS BILLED DOES NOT MEET MEDICAID GUIDELINES FOR PARING AND CUTTING OF LESIONS OR TRIMMING OF NONDYSTROPHIC NAILS
Edit 04508	EOB 07724 - DIAGNOSIS DOES NOT SUPPORT BILLING OF DEBRIDEMENT OF NAILS PER MEDICAID GUIDELINES
Edit 04509	EOB 07718 - CORONARY INTERVENTION SERVICE IS NOT CONSISTENT WITH/OR NOT COVERED FOR THIS DIAGNOSIS.
Edit 04510	EOB 07753 - MONITORED ANESTHESIA NOT SUPPORTED BY DIAGNOSIS
Edit 04511	EOB 01553 - REFER TO 1998 CPT FOR HIV VIRAL LOAD CODES AND REFILE

If a claim fails one of these edits, the provider should review the clinical coverage policies to ensure they are using the appropriate diagnosis code for the procedure that was rendered. The updated policies will be posted on the N.C. Division of Medical Assistance website by October 1. Also, bear in mind this list is not comprehensive. Other edits may be triggered by ICD-10 related errors.