Pulmonology Coding Alert

Question: We need to submit a claim with more than 12 diagnoses. Is there a way to do that? The clearinghouse we use splits claims with multiple diagnoses and often duplicates procedure and office codes, which causes issues with payers. 

Ohio Subscriber

Answer: CMS modified form 1500 to support up to 12 diagnosis codes per claim in an effort to reduce paper and electronic claims from the splitting you describe. Twelve diagnosis codes are allowed per claim; however, only four diagnosis codes are allowed per line item for each individual procedure code. That means only four diagnosis codes can “pointed” (connected) to each procedure to per claim line.

For example: On Form CMS 1500, box 21, you may have a situation where more than four diagnosis codes on a claim is vital to documenting the full extent of a patient’s illness. While there are 12 place holders for diagnoses, only a maximum of four is allowed for each single procedure performed. So, there can be up to eight floating diagnoses that can be listed as current diagnoses for that patient, but there may be additional diagnoses related to the charges that aren’t “pointed,” as four are already pointing to the procedure or there may be additional diagnoses related to the medical decision making (MDM) of the visit as current comorbidities.

Caveat: When applicable, you should not associate the same diagnosis with each line item if the primary reason for each service is different. For example, the patient with chronic obstructive pulmonary disease, atrial fibrillation, congestive heart failure and acute kidney injury may be seen for a visit due to an exacerbation of COPD. A nebulizer treatment was provided due to wheezing, and an ECG was provided due to chest tightness. In order to identify the need for each service, the physician would report COPD exacerbation as the primary diagnosis for the visit (along with wheezing and chest tightness). Wheezing could be associated as the primary reason for the nebulizer therapy (along with COPD exacerbation and chest tightness), and chest tightness could be listed as the primary reason for the ECG (along with CHF and A-fib).  Although the patient has six different diagnosis codes that could be reported on the claim, all should not be associated with each line item.