Inappropriate Primary Diagnosis Edit Effective 7/1/2023
Date: 06/01/23
Medicaid, Medicare and Marketplace claims for dates of service 7/1/2023 and after will be edited prior to payment to confirm the primary/principal diagnosis, manifestation diagnosis, and/or sequelae (complication or condition that results from a pre-existing illness, injury, etc.) diagnosis billed is appropriate on inpatient and outpatient facility UB-04 claims.
Top Five Diagnosis Denials:
Dx Code | Description |
|---|---|
S06.2X9S | Diffuse traumatic brain injury without loss of consciousness, sequela |
F02.80 | Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety |
Z76.89 | Person encountering health services in other specified circumstances |
Z23 | Encounter for immunization |
D63.1 | Anemia in chronic kidney disease |
Resources:
· ICD-10-CM Guidelines (PDF)
· Medicare Claims Processing Transmittal
Denial Reason Codes for Medicaid, Marketplace, Medicare (Except Medicare PPO):
Claim Form Type | EX Code | EX Code Description | CARC/RARC Code |
|---|---|---|---|
Outpatient UB-04 | EXcU | INAPPROPRIATE DX CODE BILLED IN PRIMARY POSITION | 16/MA63 |
Inpatient UB-04 | EXKi | INAPPROPRIATE DX CODE BILLED IN PRIMARY POSITION | 16/MA63 |
Denial Reason Codes for Medicare PPO
CODE | CODE DESCRIPTION | CODE TYPE | CARC/RARC CODE | CARC DESCRIPTION | RARC DESCRIPTION |
|---|---|---|---|---|---|
CE142 | Inpatient Unacceptable Principal DX, Requires Secondary DX | DN | 16/M64 | Claim/service lacks information needed for adjudication | Missing/incomplete/invalid other diagnosis |
CE139 | Denied: Inpatient Manifestation Code as Principal DX | DN | 146/MA63 | Diagnosis invalid for date(s) of service reported | Missing/incomplete/invalid principal diagnosis |
CE141 | Denied: Inpatient Unacceptable Principal DX | DN | 146/MA63 | Diagnosis invalid for date(s) of service reported. | Missing/incomplete/invalid principal diagnosis |
AzCH providers and staff:
If you have questions, please contact your AzCH Provider Engagement Specialist. If you need your assigned Provider Engagement Specialist’s contact information, please email us at AzCHProviderEngagement@azcompletehealth.com.
Care1st providers and staff:
If you have questions, please call Provider Network Operations at 1-866-560-4042 (Options in order: 5, 7) or email SM_AZ_PNO@care1staz.com.