• Up to twelve diagnoses can be reported in item 21 on the CMS-1500 paper claim (02/12)
DIAGNOSIS – ICD
Enter 9 for ICD-9 diagnosis codes and 0 for ICD-10
diagnosis codes. The correct code set is determined by date
Item 21 - Enter the patient's diagnosis/condition. With the exception of claims submitted by ambulance suppliers (specialty type 59), all physician and nonphysician specialties(i.e., PA, NP, CNS, CRNA) use diagnosis codes to the highest level of specificity for the date of service. Enter the diagnoses in priority order. All arrative diagnoses for nonphysician specialties shall be submitted on an attachment.
Reminder: Do not report ICD-10-CM codes for claims with dates of service prior to implementation of ICD-10-CM, on either the old or revised version of the CMS-1500 claim form. For form version 08/05, report a valid ICD-9-CM code. Enter up to four diagnosis codes. For form version 02/12, it may be appropriate to report either ICD-9-CM or ICD-10-CM codes depending upon the dates of service (i.e., according to the effective dates of the given code set).
• The “ICD Indicator” identifies the ICD code set being reported. Enter the applicable ICD indicator according to the following:
Indicator Code Set
9 ICD-9-CM diagnosis
0 ICD-10-CM diagnosis
Enter the indicator as a single digit between the vertical, dotted lines.
• Do not report both ICD-9-CM and ICD-10-CM codes on the same claim form. If there are services you wish to report that occurred on dates when ICD-9-CM codes were in effect, and others that occurred on dates when ICD-10-CM codes were in effect, then send separate claims such that you report only ICD-9-CM or only ICD-10-CM codes on the claim. (See special considerations for spans of dates below.)
• If you are submitting a claim with a span of dates for a service, use the “from” date to determine which ICD code set to use.
• Enter up to 12 diagnosis codes. Note that this information appears opposite lines with letters A-L. Relate lines A- L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. Do not provide narrative description in this field.
• Do not insert a period in the ICD-9-CM or ICD-10-CM code.
Coding and Reporting Principles
Claims-Based Reporting Principles Reporting DX for PQRS
• The 2014 Physician Quality Reporting System (PQRS) Measure Specifications contain ICD-9-CM coding and ICD-10-CM coding. Beginning 10/01/2015, the PQRS system will only accept ICD-10-CM codes for analysis.
• A new CMS-1500 claim form (02/12) is available for use to accommodate the new ICD-10-CM coding. CMS will continue to accept the old CMS-1500 claim form (08/05) through March 31, 2014. However, on April 1, 2014, CMS will receive claims on only the revised CMS-1500 claim form (02/12). Claims sent on the old CMS-1500 claim form (08/05) will not be accepted.
• Up to twelve diagnoses can be reported in item 21 on the CMS-1500 paper claim (02/12) (see the 2014 PQRS Implementation Guide) and up to twelve diagnoses can be reported in the header on the electronic claim.
o Only one diagnosis can be linked to each line item.
o PQRS analyzes claims data using ALL diagnoses from the base claim (item 21 of the CMS-1500 or electronic equivalent) and service codes for each individual EP (identified by individual NPI).
o EPs should review ALL diagnosis and encounter codes listed on the claim to make sure they are capturing ALL measures chosen to report and that are applicable to patient’s care.
• All diagnoses reported on the base claim will be included in PQRS analysis, as some measures require reporting more than one diagnosis on a claim.
o For line items containing QDC, only one diagnosis from the base claim should be referenced in the diagnosis pointer field.
o To report a QDC for a measure that requires reporting of multiple diagnoses, enter the reference number in the diagnosis pointer field that corresponds to one of the measure’s diagnoses listed on the base claim. Regardless of the reference number in the diagnosis pointer field, all diagnoses on the claim(s) are considered in PQRS analysis.
• If your billing software limits the number of line items available on a claim, you must add a $0.01 nominal amount to one of the line items on that second claim for a total charge of one penny.
o PQRS analysis will subsequently join claims based on the same beneficiary for the same dateof-service, for the same Taxpayer Identification Number/National Provider Identifier (TIN/NPI) and analyze as one claim.
o Providers should work with their billing software vendor/clearinghouse regarding line limitations for claims to ensure that diagnoses, QDCs, or nominal charge amounts are not dropped.
o In an effort to streamline reporting of QDCs across multiple CMS quality reporting programs, CMS strongly encourages all EPs and practices to begin billing 2014 QDCs with a $0.01 charge. EPs should pursue updating their billing software to accept the $0.01 charge prior to implementing 2014 PQRS. EPs and practices will need to work with their billing software or EHR vendor to ensure this capability is activated.
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