Diagnosis coding and sequencing requirements (ICD-10-CM)
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This policy governs submission of diagnosis codes on professional and facility claims for Fallon Health products, requiring valid, complete, and properly sequenced ICD-10-CM coding; it affects providers submitting claims to Fallon Community Health Plan and listed Fallon Health products.
No material clinical or coverage changes in this revision.
Coverage and Billing Criteria
Coverage and billing criteria for diagnosis coding
Coverage and payment are contingent on accurate ICD-10-CM coding, sequencing, and appropriate claim form completion as described below.
ALL of the following
- Do not report manifestation codes as first-listed/principal diagnosis.
- Follow 'code first' notes where applicable.
- Sequela generally require two codes with the residual condition sequenced first and the sequela code second.
- Do not report mutually exclusive diagnosis codes together when an ICD-10-CM Excludes1 note applies.
- Specify laterality where required; do not bill unspecified laterality codes or conflicting laterality codes from the same subcategory for the same service.
ALL of the following
- Inpatient facility: report the correct principal diagnosis in UB-04 Box 67 or electronic equivalent.
- Outpatient facility: report a diagnosis appropriate to support the primary reason for the encounter in UB-04 Box 67 or electronic equivalent.
- Professional: link the appropriate primary diagnosis to each claim line via CMS-1500 Box 24E diagnosis pointer or electronic equivalent.
ICD-10-CM Coding Rules and Claim Requirements
| Manifestation codes | May not be reported as first-listed/principal diagnosis. |
| Code first notes | 'Code first' notes must be followed. |
| Sequela | Generally require two codes, with the residual condition sequenced first and sequela second. |
| Excludes1 | Do not report mutually exclusive diagnosis codes together when an ICD-10-CM Excludes1 note applies. |
| Laterality specified | Some ICD-10-CM codes include laterality (left, right, or bilateral). Laterality must be specified; do not bill unspecified laterality codes; do not bill conflicting laterality codes from the same subcategory for the same service. |
| Inpatient facility principal diagnosis field | Report the correct principal diagnosis in the principal diagnosis field (UB-04 Box 67 or electronic equivalent). |
| Outpatient facility diagnosis field | Report a diagnosis appropriate to support the primary reason for the encounter in the diagnosis field (UB-04 Box 67 or electronic equivalent). |
| Professional claim diagnosis linkage | Link the appropriate primary diagnosis to each claim line (CMS-1500 Box 24E diagnosis pointer or electronic equivalent). |
Provider Responsibilities and Prior Authorization
No policy-specific prior authorization or referral requirements
No referral, notification, or prior authorization requirements are specific to this policy; follow the member's benefit plan documents and Fallon Health administrative policies for any general authorization requirements.
- Standard product and benefit requirements apply — check the member's benefit plan for specific prior authorization rules.
- Refer to Fallon Health administrative policies for general authorization procedures.
Key Definitions
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