We have some professional providers submitting duplicate diagnosis codes on 837P transactions. I do not see any language in the 837P Implementation Guide stating this is NOT allowed.
Question: May we reject this scenario back to the submitters with the 277CA? If so, suggested Status Category and Status Codes for the rejection? I did not see any that states duplicate. Would A7-255 suffice?
Duplicate submitted DX codes cause issues within adjudication.
The 837P TR3 guide 005010X222A1 situational rule for HI02 through HI12 states Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Sending duplicate diagnoses would not provide an additional diagnosis. Therefore, duplicate diagnoses must not be sent.
Using the Claim Status Category Code of ‘A7 – Acknowledgement/Rejected for Invalid Information – The claim/encounter has invalid information as specified in the Status details and has been rejected“ in the Health Care Claim Acknowledgment (277CA) would be appropriate. Additionally, the location of the invalid information is identified as the diagnosis code and Claim Status Code ‘255 – Diagnosis Code’ would be appropriate as well
Related RFIs: 1366
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