Rules of DX code in CMS 1500


ICD-9-CM Codes

Physicians and Non-Physician Practitioners (NPP) must use the appropriate
diagnosis code or codes to identify symptoms, conditions, problems, complaints
or other reasons for the encounter or visit.

Claims will be returned as unprocessable when the ICD-9-CM code is invalid.

Rules for Reporting Diagnosis Codes

*Use the ICD-9-CM code that describes the patient’s diagnosis, symptom,
     complaint, condition or problem. Do not code a suspected diagnosis.

* Use the ICD-9-CM code that is chiefly responsible for the item or service

* Assign codes to the highest level of specificity. Use the fourth and fifth digits
   where applicable.

* Code a chronic condition as often as applicable to the patient’s treatment. Code
    all documented conditions that coexist at the time of the visit that require or affect
  patient care or treatment. Do not code conditions that no longer exist.
ICD-9-CM Codes and Date of Service

The ICD-9-CM codes must be coded to the highest level of specificity for the date of  service, i.e., coding to the fourth or fifth digit. This is a requirement for all physician and NPP claims.

Diagnosis codes must be reported based on the date of service on the claim and not the date the claim is prepared or received.

Updated ICD-9-CM codes are effective each October 1.

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