The 005010X224A2 837 (Health Care Claim: Dental) Technical Report Type 3 (TR3) situational rule for segment HI (Health Care Diagnosis Code) in loop 2300 is ‘Required when the diagnosis may have an impact on the adjudication of the claim in cases where specific dental procedures may minimize the risks associated with the connection between the patient’s oral and systemic health conditions.’ The TR3 does not allow a diagnosis code if this condition is not true. Therefore, a dental claim may have no diagnosis code or up to a maximum of 4 depending on the nature of the dental procedure and the health of the patient.

The situational rule for data element SV311 (Composite Diagnosis Code Pointer) states ‘Required when the service relates to that specific diagnosis and is needed to substantiate the medical treatment.’ Further, the element note goes on to say ‘The first pointer designates the primary diagnosis for this service. Remaining diagnosis pointers indicate declining level of importance to the service line.’ Therefore, a service line may contain no diagnosis code pointer or up to a maximum of 4 depending on the relationship of that service to the diagnosis codes that may be present in the HI segment.

You ask whether a dental payer is required to use more than one diagnosis code in a service line.

The sender (typically a provider or payer) of an 837 dental claim transaction is required to follow the requirements above, and will therefore populate from 0 to 4 diagnosis code pointers in SV311 depending on the number of diagnoses in the HI segment that relate to the service line.

The receiver of an 837 dental claim transaction (typically a payer) is required to accept transactions with 0 to 4 diagnosis code pointers in a service line that have been reported by the sender. How the receiver uses those pointers in its business process is up to the receiver and not within the scope of X12.