# HCC Diagnosis codes on claim form-Auditors Please Reply



## rdennis (Apr 12, 2018)

We have a question from a physician regarding an imagined hindrance to him being able to report all the conditions.  He feels because he can only link 4 diagnosis codes to a line item, even though 12 were entered into box 21 of claim form, he believes the payers are only capturing those 4 diagnosis codes from a HCC perspective.  He asked if he could bill a 2nd "ghost" CPT code line item in order to link the remaining diagnosis codes which were not linked to the first line item in order to make sure all the HCC codes were reported.  I suppose he could be right, but I feel the payer for risk adjustment purposes probably capture all ICD10 codes reported in box 21 of claim form and not just those listed in box 24c (the 4 linked to the line item).  Does ANYBODY  have any guidance on this they can share?  It would be most helpful.  

Ruth, CPC, CEMC
Arkansas


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## CodingKing (Apr 12, 2018)

I'm not sure if these are the best links but may be helpful. RAPS submission uses all 12 diagnosis codes fields. I cant find any references to only codes used a diagnosis pointer as counting.


Loads of good info in this link that the claim form was increased to 12 codes to negate the needs to split claims to include more than 4.:

https://ionhealthcarepulse.com/2018/01/23/maximum-diagnosis-codes-submission-on-claim-forms/



Some other links:

https://paperinbox.wordpress.com/2013/04/22/understanding-diagnosis-pointers/




> What if more than four (4) diagnosis relate to the treatment?
> The coder who is submitting the claim at the provider picks the 4 best and does not point to the others.  The idea is to give enough detail / justification for the service being claimed to actually be paid.  If one pointer will do, then there is very little reason to point to more codes.  In the off chance other diagnosis are relevant to the treatment, they are still available to the examiner at the insurance company who is doing the adjudication – they just are not specifically pointed to.




Blue Cross RA webinar (pg 18):
https://www.bcbsla.com/docs/2016CRAWebinar.pdf




> File up to 12 diagnosis codes on the 1500 claim form




Risk Adjustment for EDS & RAPS User Group
CMS Q&A


https://www.csscoperations.com/internet/cssc3.nsf/files/021617_RAWeb_QA_formatted_5CR_050117.pdf/$FIle/021617_RAWeb_QA_formatted_5CR_050117.pdf





> Q13. Is it possible to submit more than 12 diagnosis codes for a single encounter data record?
> A13. Submitters can submit a maximum of 12 diagnoses on a single professional encounter data record and 25 diagnoses on a single institutional encounter data record.


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## Michele Price (Apr 27, 2018)

rdennis said:


> We have a question from a physician regarding an imagined hindrance to him being able to report all the conditions.  He feels because he can only link 4 diagnosis codes to a line item, even though 12 were entered into box 21 of claim form, he believes the payers are only capturing those 4 diagnosis codes from a HCC perspective.  He asked if he could bill a 2nd "ghost" CPT code line item in order to link the remaining diagnosis codes which were not linked to the first line item in order to make sure all the HCC codes were reported.  I suppose he could be right, but I feel the payer for risk adjustment purposes probably capture all ICD10 codes reported in box 21 of claim form and not just those listed in box 24c (the 4 linked to the line item).  Does ANYBODY  have any guidance on this they can share?  It would be most helpful.
> 
> Ruth, CPC, CEMC
> Arkansas



Hi Ruth, I feel your pain. We have the same problems with payers only excepting 4 diagnoses per line item. These are usually your MMA's and one company in particular is a very large insurance so I do not see the reasoning in why their software is so limited. The only way to get around this is to talk to your particular insurances that have this issue and see if you can set up a dummy code on another line item and add your diagnoses to those extra dummy codes on the other lines on the same claim. You will not need to create another claim. This would create a bigger issue then you already have. Also, you will need to be in contact with their EDI department to do this. If the issue is your software, then I would talk to your software company and see if they can do an update. Make sure that your software or EMR is capable of doing this and their (insurances) front end edits will be relaxed enough to allow it. 

I hope this helps and good luck. 

Michele Price, CPC


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