We received a 999 rejection of a claim where the diagnosis code exists in the ICD9 code list but its description states that codes of more specificity be used. Is this Implementation guide conformance or application validation?
The X12C Communications and Controls Subcommittee reviewed your question:
We received a 999 rejection of a claim where the diagnosis code exists in the ICD9 code list but its description states that codes of more specificity be used. Is this Implementation guide conformance or application validation?
The 999 Implementation Acknowledgement purpose and scope states:
“This X12 Transaction Set contains the format and establishes the data contents of the Implementation Acknowledgment Transaction Set (999) for use within the context of an Electronic Data Interchange (EDI) environment. The transaction set can be used to define the control structures for a set of acknowledgments to indicate the results of the syntactical and relational analysis of the electronically encoded documents, based upon a full or implemented subset of X12 transaction sets. The encoded documents are the transaction sets, which are grouped in functional groups, used in defining transactions for business data interchange. This standard does not cover the semantic meaning of the information encoded in the transaction sets.”
Per your example, receiving a 999 for the rejection of a code value which exists in the referenced code list (i.e. ICD-9) would violate the conformance to the code list referenced in the implementation guide. This should not be reported on the 999.
The question of whether or not the code meets your trading partner’s business requirements to conduct business would either be reported on the 277 Claims acknowledgment or via the 835 remittance advice both of which are application/trading partner specific validations.