Submit the Most Specific Diagnosis Code(s) to Avoid Claim Line Denials
Horizon 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.
We continue to see a high number of claim bill line denials with the message: THIS SERVICE IS NOT PAID. THE SUBMITTED DIAGNOSIS CODE IS NOT SPECIFIC ENOUGH FOR ACCURATE DETERMINATION OF BENEFIT ELIGIBILITY.
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.
Such denials are based on ICD-10-CM Official Guidelines for Coding and Reporting pertaining to "Excludes1" notes which indicate 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.
- 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 the most accurate and current codes are submitted, Horizon is able to quickly and efficiently process claims and generate accurate and appropriate reimbursement for the health care services you provide to our members.