Health Care Claim

Health Care Claim: Diagnosis Coding (Texas Medicaid)

Health Care Claim must be coded by electronic billers. Health Care Claim is processed fast and accurately if providers furnish appropriate information. By coding EDI Health Care Claim, providers ensure precise and concise representation of the services provided and are assured reimbursement based on the correct code. If providers code claims, a narrative description is not required and does not need to be included unless the code is a not an otherwise classified code.

Claims for anesthesia must have the CPT anesthesia procedure code narrative descriptions or CPT surgical codes; if these codes are not included, the claim will be denied.

Diagnosis Coding

Texas Medicaid requires providers to provide International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes on their claims. The only diagnosis coding structure accepted by Texas Medicaid is the ICD-10-CM. Diagnosis codes must be to the highest level of specificity available. In most cases a written description of the diagnosis is not required. All diagnosis codes that are submitted on a claim must be appropriate for the age of the client as identified in the ICD-10-CM description of the diagnosis code. Claims that are denied because one or more of the diagnosis codes submitted on the claim are not appropriate for the age of the client may be appealed with the correct diagnosis code or documentation of medical necessity to justify the use of the diagnosis code.

Diagnosis codes in the following categories are not valid as primary or referenced diagnosis:

  • Nonspecific injury, poisoning and other consequences of external causes
  • Diagnosis in the International Classification of Diseases for Oncology, 3rd Edition (ICD-O-3)
  • Factors influencing health status and contact with health services, unless otherwise directed in this manual
  • External causes of morbidity

Place of Service (POS) Coding

The POS identifies where services are performed. Indicate the POS by using the appropriate code for each service identified on the claim. Attention ambulance providers: POS 41 and 42 are accepted by Texas Medicaid for ambulance claims processing. The two-digit origin and destination codes are still required for claims processing.

To learn more about Health Care EDI claims and become a certified  EDI Professional please visit our course schedule page.

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