<p>Page 1 of 7 4/28/2018 Medical Necessity Diagnosis Coding</p><p>EXAMPLE 1 – CLAIM EDIT FOR INVALID DX</p><p> BILLER AND MEDICAL CODER TO COMMUNICATE REGARDING REVIEW OF THE PATIENT’S MEDICAL RECORD. CODER TO DETERMINE IF THE MEDICAL RECORD DOCUMENTATION SUPPORTS MEDICAL NECESSITY AS STATED IN THE LCD. </p><p>Page 2 of 7 4/28/2018 EXAMPLE 2 – CLAIM EDIT FOR INVAILD DX</p><p> BILLER AND MEDICAL CODER TO COMMUNICATE REGARDING REVIEW OF THE PATIENT’S MEDICAL RECORD. CODER TO DETERMINE IF THE MEDICAL RECORD DOCUMENTATION SUPPORTS MEDICAL NECESSITY AS STATED IN THE LCD. </p><p>CODE PAIR & LCD ID NUMBER L28300 SUMMARY </p><p>Page 3 of 7 4/28/2018 Gender Specific Diagnosis Coding EXAMPLE - CLAIM EDIT INVALID DX FOR PATIENT GENDER</p><p>Note: Placenta is an organ that develops within all female mammals during pregnancy. </p><p> BILLER AND MEDICAL CODER TO COMMUNICATE REGARDING REVIEW OF THE PATIENT’S MEDICAL RECORD. CODER TO DETERMINE THE GENDER SPECIFIC DIAGNOSIS PER MEDICAL RECORD. </p><p>Note: The prostate is a gland found in the male reproductive system.</p><p>Page 4 of 7 4/28/2018 Payer Specific CPT Coding </p><p>EXAMPLE - CLAIM EDIT CPT NOT RECOGNIZED BY PAYER</p><p> Note: Change Request (CR) 6740, which alerts providers that effective January 1, 2010, the Current Procedural Terminology (CPT) consultation codes (ranges 99241–99245 and 99251–99255) are no longer recognized for Medicare Part B payment. Effective for services furnished on or after January 1, 2010, providers should code a patient evaluation and management visit with E/M codes that represents where the visit occurs and that identify the complexity of the visit performed. Only applies to billing for physician services under the Medicare fee-for-service program. It does not revise existing policies or rules governing Medicare Advantage or non-Medicare insurers.</p><p>Additional Information If you have any questions, please contact toll-free J1 Provider Contact Center. For Part A call (866) 931-3906 or for Part B call (866) 931-3901. The official instruction, CR6740, issued to Medicare MACs and carriers regarding this change may be viewed at www.cms.hhs.gov/transmittals/downloads/R1875CP.pdf on the CMS Web site. You may also want to review the related article SE1010 (Questions and Answers on Reporting Physician Consultation Services), which may be found at www.cms.hhs.gov/MLNMattersArticles/downloads/SE1010.pdf on the CMS Web site. </p><p>Page 5 of 7 4/28/2018 The E/M documentation guidelines are available at www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp on the CMS Web site. CPT Modifiers - CPT APPENDIX A </p><p>EXAMPLE - CLAIM EDIT MISSING CPT MODIFIER </p><p>REFERENCE CPT MANUAL APPENDIX OF A - MODIFIERS</p><p>Page 6 of 7 4/28/2018 EXAMPLE OF A CMS 1500 HEALTH INSURANCE CLAIM FORM (PATIENT DATA IS FICTIOUS)</p><p>Note: For CMS 1500 CLAIM FORM INSTRUCTIONS REFERENCE </p><p>Page 7 of 7 4/28/2018</p>