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DVHA’s Coding Team and Clinical Operations Unit performs a review of the ICD-10-CM diagnosis code restrictions in the claims adjudication system on a quarterly basis. The below lists are updated quarterly.

Your use of ICD-10-CM Diagnosis Codes could cause your claims to deny due to two primary reasons:

  1. 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.

    July 2024 | April 2024 | January 2024


  2. 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; however, 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.

    July 2024 | April 2024 | January 2024


If any questions, please contact your Gainwell Provider Representative.