Diagnosis Code Reporting

Diagnosis Code Reporting And Reporting National Drug Codes

Diagnosis Code Reporting subjects to the International Classification of Diseases (ICD) – a medical code set maintained by the World Health Organization (WHO). It was developed so that medical terms reported by physicians, medical examiners, and coroners can be grouped together for statistical purposes. Effective October 1, 2015, the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) is the standard for reporting patient diagnoses, replacing ICD-9-CM. ICD-10 provides more specific data than ICD-9 and better reflects current medical practice. The added detail embedded within ICD-10 codes informs health care providers and health plans of patient incidence and history, which improves the effectiveness of case management and care coordination functions. Highmark will accept only ICD-10-CM diagnosis codes on claims for dates of service October 1, 2015 and after. Please Note: ICD-10 diagnosis code reporting does not directly affect provider use of the Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes.

Highmark requires you to report the highest level of specificity when reporting diagnosis codes on medical-surgical claim forms. Since Highmark’s claims processing system applies medical payment guidelines based on diagnosis codes, you must report the most appropriate diagnosis code(s) on every claim. The diagnosis must be valid for the date of service reported. Highmark will reject your claims for payment if you submit them without complete or accurate diagnosis codes. NaviNet® includes a diagnosis code inquiry that lets you look up diagnosis codes by code or description, and also provides effective dates and end dates for the codes.

Reporting National Drug Codes 

Many NDCs are displayed on drug packaging in a 10-digit format. Proper billing of an NDC requires an 11-digit number in a 5-4-2 format. Converting NDCs from a 10- digit to an 11-digit format requires a strategically placed zero, dependent upon the 10-digit format. The following table shows common 10-digit NDC formats indicated on packaging and the associated conversion to an 11-digit format, using the proper placement of a zero. The correctly formatted additional “0” is in a bold font and underlined in the following example. Note that hyphens indicated below are used solely to illustrate the various formatting examples for NDCs. Do not use hyphens when entering the actual data in your paper claim form.

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