Wiki Billing diagnosis on a claim line but not associating with a line on HCFA claim.

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I work for an insurance company which sells Medicare Advantage plans, which are we receive payment from CMS based on the beneficiaries risk adjustment score and we need all of the members diagnoses in order for the score to be calculated. Therefore, we require our in-network providers to submit all diagnoses applicable to a patient. It is quite common to see all 12 diagnosis fields populated in box 21 of a HCFA, even though you can only list up to 4 diagnosis codes to a given line item on the claim. If only 1 diagnosis code applies to a service being billed, but the patient has additional conditions/diagnoses, you would bill the procedure/service and only link diagnosis A, the primary diagnosis for the visit, to the line item. For example:

Patient has diagnoses listed in fields A & B in box 21 of the HCFA claim form; however, the only condition addressed during the office visit is E11.649, you would only list A in the Diagnosis Pointer field E of box 24.

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Does this make sense and help? If not please don't hesitate to message me directly and I'll try to assist you further.
 
There are billing programs that will not let you list a diagnosis on a claim if there is no pointer for it, as the diagnoses are entered at the claim line level. If it's not on a claim line, it's not on the HCFA (FOR ME).
 
The 2 most recent programs I've used will not let you put a dx on the HCFA if it is not linked to at least procedure.
 
SharonCollachi said:
There are billing programs that will not let you list a diagnosis on a claim if there is no pointer for it, as the diagnoses are entered at the claim line level. If it's not on a claim line, it's not on the HCFA (FOR ME).
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Our ACO advised us that we could add cpt code 99080 with a zero charge to the claim and attached the patient conditions/diagnosis to report those add'l codes.
 
pcapozzoli said:
Our ACO advised us that we could add cpt code 99080 with a zero charge to the claim and attached the patient conditions/diagnosis to report those add'l codes.
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HI I work for an ACO too and we've been submitting sibling "penny" claims to medicare using 99499 but we don't see the diagnosis codes on the CCLF file when we reconcile. Has your ACO ever dealt with this scenario?
 
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