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Avoid Claim Line Denials by Billing Most Specific Diagnosis Code(s)

Horizon BCBSNJ continually works to ensure that our code and claim-editing rules are up-to-date with standard business practices and that code- and claim-editing rules are fully and correctly implemented within our claim processing systems.

Following a recent update to our code- and claim-editing rules, we have noticed a high number of claim bill line denials that include the message: THIS SERVICE IS NOT PAID. THE SUBMITTED DIAGNOSIS CODE IS NOT SPECIFIC ENOUGH FOR ACCURATE DETERMINATION OF BENEFIT ELIGIBILITY.

These claim bill line denials are based on ICD-10-CM Official Guidelines for Coding and Reporting pertaining to Excludes1 notes:

  • An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates that the two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. The billed service was denied because it was reported with one or more diagnosis code pairs that are subject to an Excludes1 note.

Based on our review, a large number of these claim bill line denials are the result of ICD-10 diagnosis coding that does not use the highest level of specificity. If you feel that denied claim bill lines should be reconsidered for reimbursement, please submit a corrected claim that includes the highest appropriate level of specificity.

We encourage all health care professionals, facilities and ancillary providers and their billing offices and vendors to continue to work to ensure a high-level of accuracy and compliance with the most current and appropriate billing practices, rules and guidelines.

When you submit the most accurate and current codes, Horizon BCBSNJ is able to quickly and efficiently process claims and generate accurate and appropriate reimbursement for the health care services you provide to our members.

Published on: January 22, 2020, 03:48 a.m. ET
Last updated on: June 16, 2021, 16:09 p.m. ET