Coding of Claims/Billing Codes
Louisiana Healthcare Connections requires claims to be submitted using codes from the current version of ICD‐9‐CM, ICD‐10, ASA, DRG, CPT4, and HCPCS Level II for the date of service was rendered. These requirements may be amended to comply with federal and state regulations as necessary.
Below are some code-related reasons a claim may be rejected or denied:
- CPT/HCPCS code billed is missing, invalid or deleted at the time of service.
- CPT/HCPCS code inappropriate for the age or sex of the member.
- ICD-9cm diagnosis code missing the 4th or 5th digit as appropriate.
- A deleted ICD-9cm code was used.
- Procedure code pointing to a diagnosis code that may not reflect medical necessity of procedure performed. For a HCFA 1500 claim form, this criteria looks at all procedure codes billed and if the diagnosis code is pointing to a procedure code and the diagnosis code is invalid and/or does not support medical necessity, the claim line will be denied.
- Using a secondary only designated as the primary diagnosis code on the claim as a primary diagnosis the service line on the claim will deny.
- CPT/HCPCS code billed is inappropriate for the location or specialty billed.
- CPT code billed is a part of a more comprehensive code billed on same date of service.
- Rev Code/HCPC Code combination billed not appropriate
Written descriptions, itemized statements, medical records, and invoices may be required for Unlisted CPT/HCPCS codes upon submission of a claim or at the request of Louisiana Healthcare Connections.
When sending requested medical records, providers should also attach the original claim form and/or claim number to medical records. If original claim form or claim number is not submitted with the medical records, the MRU will not review medical records.
To learn more about HIPAA EDI Claims Procedures and become a certified EDI Professional, please visit our course schedule page.