DVHA’s Coding Team and Clinical Operations Unit has performed a review of the ICD-10-CM diagnosis code restrictions in the claims adjudication system on a quarterly basis. As of August 1, 2022, the below lists will be updated quarterly.
Your use of ICD-10-CM Diagnosis Codes could cause your claims to deny due to two primary reasons:
- The ICD-10-CM Diagnosis Code is not allowed as the Primary Diagnosis on the claim.
These diagnosis codes are often unspecified and will not be accepted on claims in the primary diagnosis position, but may be appropriate to report in a secondary position.
- The ICD-10-CM Diagnosis Code is not allowed to be reported to Vermont Medicaid due to a lack of specificity related to laterality.
These diagnosis codes have a choice for left, right, bilateral, and unspecified… but the unspecified code will not be accepted on claims in any diagnosis position. You should choose the most specific code outlined in the medical record. If the provider did not specify in the medical record, please reach out to the provider to specify and amend the record.
Questions? Please contact your Gainwell Provider Representative.