CPT code 96372 medicare: Medicare does not cover the entire cost of CPT 96372. 3 0 obj
If 2300.HI01-1 is "APR" then 2300.HI01-2 must be a valid ICD-10 Patient Reason for Visit code, otherwise claim is rejected. The diagnosis code supports the medical necessity for the service and tells the payer why the service was performed. <>
This amounts to typically ~13-20% more per session. While the Data Dictionary directs that procedure codes on outpatient facility claims in the OT file are expected to be reported in the HCPCS-RATE field, effective January 1, 2021 states that are currently populating the OT HCPCS-RATE should cease doing so. Preventive. Denial: Valid Procedure codes can be either ER, HC, IV, or WK. - AAPC Does Wellcare use the Center for Medicare & Medicaid Services (CMS) ICD-10 General Equivalency Maps (GEMs) crosswalks? In ICD-10-PCS, there are two root operations for this procedure, Bypass and Excision. Z No Qualifier A Hip Joint, Acetabular Surface, Right E Hip Joint, . All claims are dependent upon a valid diagnosis code being submitted. This field is not currently required on outpatient claims. SV101-2. Topical Flouride Treatment Figure 4. Currently in ICD-9 we use 04.81, injection of an anesthetic, or 04.81, 04.89 and 99.23 if it is a combination of anesthetic and steroid with CPT 64415 and an X modifier added to the CPT code. information necessary to construct a procedure code. CSC 232: "Admitting Diagnosis Code". Receive 999E with:
6: In what situations are diagnosis codes required on a prescription? Diagnoses are to be coded using valid international classification of diseases (ICD)-9/10 CM codes. States should report the diagnosis in T-MSIS as coded and identified by the medical service provider and should be full valid ICD 9/10 CM codes without a decimal point. Here are three steps to ensure you select the proper ICD-10 codes: When sending more than one diagnosis code, use the qualifier code ABF for each Other Diagnosis Code to indicate up to 24 additional ICD-10 diagnosis codes that are sent. All claims processed and paid are based upon procedure code fee schedules or Optum Pricers. CSCC A7: "Acknowledgement /Rejected for Invalid Information"
hk6=A6
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c4ogecY(dRfgB*(I]bP4RtyyQm?|(esW\V/sOug:StLjj/.$Z6o?6zZjYh l[4}x.e/]0S[-fiK]!M71!CH|Y=_jfm/MX=E*7_j!cJ9O36^ >M6SxJ3'$ZkVJag9612|Ad+1`P@)SFxL >p5L002|om!CooB_mT How would an interscalene pain block of a nerve post orthopedic procedure be coded? DrChrono will automatically print procedure cod qualifier "0" to indicate ICD-10 codes are being used. When there is more than one iteration of 2300.HI with HI01-1 = "BK" or "ABK" the claim is rejected. E-P Q@L(Sq4#koIG%J{,oMqnB5n/u'7cc~3NM~Ih/OLh
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)WfJ;hz_-P Box 74 - Where do I add the Principal Procedure Code for an inpatient Copyright 2023 Kareo, Inc. All Rights Reserved, Discharge Date (DTP-01=096) was not expected because this claim is not for Inpatient Services. The accommodation rate on an inpatient claim may be entered in this field (optional). CSC 454: "Procedure code for services rendered.". Enter a Melbet promo code and get a generous bonus, An Insight into Coupons and a Secret Bonus, Organic Hacks to Tweak Audio Recording for Videos Production, Bring Back Life to Your Graphic Images- Used Best Graphic Design Software, New Google Update and Future of Interstitial Ads. Revision to 1 Category I code ( 0173A) and addition of 1 Category I code (0174A) accepted by the CPT Editorial Panel. When diagnosis codes are included on OT claims, diagnosis codes should be reported in T-MSIS as coded and identified by the medical service provider and should be full valid ICD 9/10 CM codes without a decimal point. 11 Qualifiers of possibility: Could, may, likely, possible, probable, etc. Wellcare has the ability to auto-adjudicate ICD-10 claims in the same manner we auto-adjudicated ICD-9 claims. CSC 465: "Principal Procedure Code for Service(s) Rendered". Two codes are assigned for the four vessel coronary artery bypass and an additional code is assigned for excision of the greater saphenous vein. What is a qualifier in coding? - KnowledgeBurrow.com We use cookies to ensure that we give you the best experience on our website. %PDF-1.5
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CSC 490:"Other Procedure Code for Service(s) Rendered". 4 What is the code for more than one ICD-10 diagnosis? Any advice? .46%~;u5RTiU7\&O]9,E5[-GWU,=XN%V:*
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o1-H\I2.zuZ^gg6/( NRtOS,mB`l)@-`l}H~aMj*v7xw21}iNUV?YFF)f:7mq.t[)4^bqKP3;_F#4qXF&C]r8UppR/d/WUZ/VDp`~9(hj?a1.Gr9er3_.Bqy%Js&)~PC`pNOyS0r~QF!tP This data element will no longer be required, the Data Dictionary will be updated to reflect this change, and states will be notified in advance. Here are the diagnosis and procedure codes we submitted on the claim: I70.219, I65.8 37236-LT, 37237-LT, 35475-59, 75710-26-59, 75962-26 Has anyone seen this before? Service ID qualifier =HC. This approach involves a picture or minor incision through the skin or mucous membrane and any other body layers necessary using instrumentation to reach the site for the procedure. Then, rebill and resubmit all affected claims. Step 3: Review the chapter-specific coding guidelines. Drug Unit Count Code Qualifier is required and must be valid Example: Bypass from stomach to jejunum, stomach is the body part and jejunum is the 626 0 obj
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CPT Code Description. Receive 277CA with:
SV101-4. CMS-1500 . Receive 999A and 277CA with:
FL 50A (Required), B (Situational), and C (Situational) - Payer Identification If Medicare is the primary payer, the provider must enter "Medicare" on line A. CMS 1500 Claim Processing Update: Qualifiers must accompany Dates Washington, D.C. 20201 The principal procedure should be reported in T-MSIS using the PROCEDURE-CODE-1 field with secondary and other procedures reported in fields PROCEDURE-CODE-2 through 6. 602 0 obj
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DISCLAIMER: The contents of this database lack the force and effect of law, except as Box 66 - Procedure Code Qualifier - DrChrono Customer Success PDF J-Code to National Drug Code - Providers Receive 999A and 277CA with:
PDF X12-837 INPUT DATA SPECIFICATIONS 2011 - New York State Department of g 5NB x&
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The Centers for Medicare and Medicaid Services (CMS) maintain the catalog in the U.S. releasing yearly updates. For X12 837I 5010A1 claims, the HI01-1 field for the Principal Diagnosis Code List Qualifier Code must contain the code "ABK" to indicate the principal ICD 0J9M0ZZ is a SURGICAL procedure assigned to MS-DRG 579-581 (Other Skin, Subcutaneous Tissue and Breast Procedures) Incision and Drainage (I & D) Skin and/or Subcutaneous Tissue If the abscess cavities were incised and opened, so that the site of the procedure was exposed it is considered an OPEN procedure and not percutaneous. 2. Qualifiers of necessity: Must, should, ought, required, have to, etc. These two-digit qualifiers should be used as appropriate in fields 17a, 24I, 32b and 33b of the revised 1500 claim form. All medical policies were reviewed for the ICD-10 transition. Immediately after the last digit of the NDC, enter the appropriate qualifier for the . Prior Authorization Requirement Summaries, Code Lists and - BCBSIL We received a denial from Medicare: EDRC-Invalid Procedure Code Qualifier for Procedure Procedure 2: 37237. A qualifier provides specificity regarding an additional attribute of the procedure, if applicable. U.S. Department of Health & Human Services Receive 999A and 277CA with:
If 2300.HI01-1 is not equal to "BK" or "ABK", the claim is rejected. PDF ICD-10-PCS Official Guidelines for Coding and Reporting The seventh character (qualifier) defines a qualifier for the procedure code.
It will only cover 80% of the cost of this procedure. The qualifier value domain is defined as including all the subtypes of the concept 362981000 |Qualifier value|.
CSC 509: "E-Code", Hours of Operation
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Only two iterations of 2300.HI with HI01-1 = "BQ" or"BBQ" are allowed, otherwise claim is rejected. off-label Avastin) 589 0 obj
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Part A ICD-10 Edits - EDI Support Services - edissweb.com Medicare payment basics Medicare qualifier list code and definition by Lori Qualifier List 0B - State License Number 1A - Blue Cross Provider Number 1B - Blue Shield Provider Number 1C - Medicare Provider Number 1D - Medicaid Provider Number 1G - Provider UPIN Number 1H - Campus Identification Number 1J - Facility ID Number %PDF-1.5
The PCS Tables should always be consulted to find the most appropriate valid code. CSCC A7: "Acknowledgement /Rejected for Invalid Information"
SPARCS INPUT DATA SPECIFICATIONS 5 Segment Loop Element Name Pages NTE02 2300 Source of Payment Typology II 172 NTE03 2300 Source of Payment Typology III 173 HI01-1 2300 Principal Diagnosis Code List Qualifier 174 HI01-2 2300 Principal Diagnosis Code (Previously Principal/Primary Diagnosis Code) 175-176 HI02-1 2300 Admitting Diagnosis Code List Qualifier 177 Biopsy procedures are coded using the root operations Excision, Extraction, or Drainage and the qualifier Diagnostic depending on the technique used to obtain the sample and whether the biopsy material is fluid, cells or tissue. Being familiar with pertinent ICD-10-CM and ICD-10-PCS coding guidelines and knowing a little about what the ICD-10-PCS character values for these codes represent will go a long way in helping [] What are the steps to selecting a diagnosis code? Units of drugs must be accurately reported in terms of dosage specified in Health Care Procedure Code System (HCPCS) descriptor. IP claims are expected to have procedure codes reported in T-MSIS as coded and identified by the medical service provider when procedures are performed during an inpatient stay. If 2300.HI01-1 is "BBQ" then 2300.HI01-2 must be a valid ICD-10 Other Procedure code, otherwise claim is rejected. Once they process the form, they will contact you at the phone number you listed as your contact phone number. These values can also be used in expressions to refine the meaning of a concept or in the appropriate fields of a health record to add additional information. If 2300.HI01-1 is "ABK" then 2300.HI01-2 must be a valid ICD-10 Diagnosis code, otherwise claim is rejected. IK403 = I12: "Implementation Pattern Match Failure"
what is a procedure code qualifier - Barri Ann Travel endstream
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<. Dental claims will have Dental Procedures and Nomenclature codes, generally referred to as CDT codes, instead of CPT codes. CSC 254: "Principal diagnosis code. Only two iterations of 2300.HI with HI01-1 = "BF" or "ABF" are allowed, otherwise claim is rejected. ChiroCode.com for Chiropractors CMS 1500 Claim Form Code-A-Note - Computer Assisted Coding Codapedia.com - Coding Forum Q&A CPT Codes DRGs & APCs DRG Grouper E/M Guidelines HCPCS Codes HCC Coding, Risk Adjustment ICD-10-CM Diagnosis Codes ICD-10-PCS Procedure Codes Medicare Guidelines NCCI Edits Validator NDC National Drug Codes NPI Look-Up . In ICD-10-PCS, the coding professional must understand the intent of the lumbar puncture in order to identify the correct root operation. Procedure modifier 3. It may not display this or other websites correctly. Only bill for the amount given to each patient. CSCC A7: "Acknowledgement /Rejected for Invalid Information"
ICD-9 & ICD-10 Qualifiers and Code Validation. %PDF-1.6
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This information is critical and is associated with the T-MSIS priority item (TPI) Completeness of Key Claims Service Data Elements TPI-20. Explanation Principal Procedure: Where should you begin to look up the code in the coding manual - ICD-10-PCS Alphabetic Index What is the type of procedure - New technology What is the procedure performed - Introduction What is the body part - Peripheral vein What is the substance - Isavuconazole anti-infective What is the New Technology group - 1 What is the character 1: Section Character . States can submit up to 2 diagnosis codes per claim on the OT file. Receive 999A and 277CA with:
Diagnosis code pointer (A submitter must point to the primary diagnosis for each service line) SV107-2. More FAQs: Strategy | Policy and Procedure | Testing. Coding for Injectable Drugs - American Academy of Ophthalmology 636 0 obj
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Copyright 2023 Wellcare Health Plans, Inc. We will follow Wellcare's current process, which is to issue authorizations based on request date. CSCC A7: ""Acknowledgement /Rejected for Invalid Information"
CSC 732: "Information submitted inconsistent with billing guidelines." This rejection is due to amissing or invalid "Drug Unit Count CodeQualifier for procedure (CPT/HCPCS)codes with an 11-digit National Drug Code (NDC) number. Effective April 1, 2019 Horizon BCBSNJ will change the way we process certain paper CMS 1500 claim form submissions to align our processing approach with how we process electronic transaction submissions. CSC 490: "Other Procedure code for services rendered.". On the OT file, financial transactions, denied and voided claims, and atypical services such as taxi services, home and vehicle modifications and respite services are not expected to have procedure codes. When there is no drug-specific procedure code: -Use an appropriate unlisted code, and -Bill at acquisition cost. If a device is taken out and a similar device put in without cutting or puncturing the skin or mucous membrane, the procedure is coded . 8:00 A.M. - 7:00 P.M. (CT)
IK403 = I12: "Implementation Pattern Match Failure"
Claims for services and inpatient procedures provided before the compliance date must use ICD-9 codes. CSCC A7: "Acknowledgement /Rejected for Invalid Information"
IK403 = 7: "Invalid Code Value". stream
The following is an example of how ICD-9-CM and ICD-10-PCS compare in code assignment for Extraction procedures. Principal Procedure Code Qualifier 2300 HI01-1 BBR - Principal Procedure Code Principal Procedure Code HI01-2 Other Procedure Code Qualifier 2300 HI01-1 through HI12-1 BBQ - Other Procedure Codes Other Procedure Code 2300 HI01-2 through HI12-2 .
If 2300.HI01-1 is "ABJ" then 2300.HI01-2 must be a valid ICD-10 Diagnosis code, otherwise claim is rejected. It is quite possible that other diagnoses and their associated codes may be appropriate for a given clinical scenario. ) BB]W`x. Receive 999A and 277CA with:
including individuals with disabilities. 1 0 obj
Why ICD-10? It's critical to check member eligibility and benefits through the Availity Provider Portal or your preferred vendor portal prior to every scheduled appointment. When sending more than one diagnosis code, use the qualifier code "ABF" for the Code List Qualifier Code to indicate up to 11 additional ICD -10 diagnosis codes that are sent. IK403 = I12: "Implementation Pattern Match Failure"
11 Unlisted HCPCS codes J3490 J3590 J7599 J7699 J7799 J8499 J8999 J9999 J7999 valid for a compounded drug (e.g. Enter the name (First Name, Middle Initial, Last Name) followed by the credentials of the professional who referred or ordered the service (s) or supply (ies) on the claim. This is demonstrated in the PCS Alphabetic Index: Biopsy see Drainage with qualifier Diagnostic endstream
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Receive 999E with:
It can be the source of denial if it doesnt show the medical necessity for the service performed. Box 21 - Procedure Code Qualifier - DrChrono Customer Success Procedural Terminology (CPT ) codes, when drugs are billed on professional/ancillary electronic (ANSI 837P) and paper (CMS-1500) claims. CSCC A7:"Acknowledgement /Rejected for Invalid Information"
PDF Qualifiers for ICD-10 Diagnosis Codes on Electronic Claims EDI Support Services
Procedure Code Qualifier Definition can offer you many choices to save money thanks to 14 active results. SV107-3. code qualifier strength strength strength volume volume name number unit unit strength j0735 ml 1000mcg/10 1000 mcg ml 10 0.1 clonidine hcl/pf j0735 ml 5000mcg/10 5000 mcg ml 10 0.5 clonidine hcl/pf last update: september 18, 2017 page 6 of 45 . Does Wellcare still accept ICD-9 codes? PO Box 6729
hb```,@(q&lNk' Include National Provider Identifier (NPI) information where indicated. Receive 277CA with:
The diagnosis code supports medical necessity and tells the payer why the service was performed. ICD-10-PCS Root Operation Groups - AHIMA Procedure modifier 4. The qualifier indicates the role of the provider being reported. Preventive. endstream
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Coding Root Operations with ICD-10-PCS: Understanding Drainage - AHIMA PROCEDURE-CODE-FLAG on the OT file should be coded "01" (CPT 4) or "06" (HCPCS) to indicate the code set used. The seventh character (qualifier) defines a qualifier for the procedure code. Diagnosis codes are used in conjunction with procedure information from claims to support the medical necessity determination for the service rendered and, sometimes, to determine appropriate reimbursement. CSC 732: "Information submitted inconsistent with billing guidelines." SV107-1. At the time of manufacture, the air in the container is replaced by nitrogen. This can lead to confusion in how states should submit data to T-MSIS. Procedure modifier 1. General Equivalency Maps (GEMs) were used along with Wellcare custom clinical and coding mappings to address gaps in GEMs during the transition. On October 1, 2015 the conversion from the 9th version of the International Classification of Diseases (ICD-9-CM) to version 10 (ICD-10-CM) occurred. The specifications in the guidance provide an explanation on how the data elements should be populated to ensure that diagnoses and procedures covered by Medicaid are accurately reported in the states T-MSIS file submission. Follow the steps below depending on whether theNational Drug Code (NDC) number was entered in the Procedure or Encounter record. This guidance is intended to address that confusion. hb``Pe``e```z01G*308121f0J4/X*P$i>Xm`P``i1?9d(Hw etb?
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CPT4 Codes Rev Codes: Mod 1 Mod 2: Mod 3 Mod 4: Units Service Description: Effective Date Comments: Primary Home Care/ PAS Type Services for members 21 and over HC S5125: U7 U5: 1 hour = 1 unit PAS Agency Model (Non-SPW) January 1, 2006: HC S5125: PDF Billing Requirements Health Systems Division August 2019 - Oregon a. Explanation principal procedure where should you - Course Hero (This does not apply to CPT coding for outpatient procedures.) Claim submission must designate a transaction as ICD-9 or ICD-10 using the qualifier field. CSCC A7: "Acknowledgement /Rejected for Invalid Information"
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Bx eC3l0AP Hp4M>Ufxp10H pYIq9S 43 . CMS Guidance: Diagnosis, Procedure Codes | Guidance Portal - HHS.gov CSC 673: "Patient reason for visit". CSCC A7: "Acknowledgement /Rejected for Invalid Information"
Receive 277CA with:
However, OT claim records for medical services, such as outpatient hospital services, physicians services, or clinic services are generally expected to have at least one diagnosis code. _K~}_'s_8_?>V>F
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If the diagnosis code is not blank, the corresponding diagnosis code flag should be populated with a valid value. Product Charge - Charges for products sold by the practice. Across the three claims files states should not duplicate diagnoses within a claim for reporting purposes. hb```B eah@t LVejG8:(pfb9 2i
mkjU D3w~lzIqqcn&86{(y5m]bi^bi/Y"ig Coding Tip of the Month - March 2020 - UASI Solutions Beginning April 1, 2019, paper CMS 1500 claim submissions that include a date within fields 14 and 15 must also include an appropriate Qualifier value (as noted in the table in below) to . endobj
What is claim diagnosis code? CSCC A7: "Acknowledgement /Rejected for Invalid Information"
Depending on your credentials, we've found that 90837 can pay between $9-20 more on average than a 90834 appointment. CMS 1500 claim form and UB 04 form- Instruction and Guide 02. CMS has confirmed that nearly all states report the procedure code on outpatient facility claims in the OT file in the PROCEDURE-CODE field. Keep Up to Date on ICD-10 Qualifiers of certainty: I guess, I think, I know, I am absolutely certain, etc. Dollar amount is driven by either the CPT, HCPC, Rev Code or DRG assigned to the claim. However, not all claims and encounters require, or should be populated with diagnosis and procedure codes. CSC 454: "Procedure code for services rendered.". PDF NDC/UPN EDI Billing Requirements - L.A. Care Health Plan Do not bill for the full amount of a drug when it has been split between two or more patients. If the bill code only has a national revenue code shown, no entry will be found in the procedure code qualifier field. 200 Independence Avenue, S.W. [1] While the T-MSIS data dictionary lists ICD-10 CM PCS the relevant set of procedure codes are referred to as ICD-10 PCS.. j0743 250 mg hcpc ndc unit ndc . Guidelines and parenthetical notes are only effective for codes that have received FDA Emergency Use Authorization (EUA) approval. Dental claims will have Dental Procedures and Nomenclature codes, generally referred to as CDT codes, instead of CPT codes. &MEs4 Onr`(zb8$cX 0ChJ;p,0ipiq210\ )?OUXZh8p. Since its creation, the form has advanced to being predominantly used . All other claims specific details should be entered on the same service line. PDF 837 Transactions Impacted by ICD10 - IVHP 3 What is difference between diagnosis code and procedure code? Only one iteration of 2300.HI with HI01-1 = "BJ" or "ABJ" is allowed, otherwise claim is rejected. This code is a composite data structure. 10D00Z1 is a billable procedure code used to specify the performance of extraction of products of conception, low, open approach. enter up to 4 2-digit modifier codes after the procedure code with no spaces. Other Preventive Services. CPT Code 90837 Reimbursement Rates. Disputed Code : J3301 NDC# 00003-029-320 Maximum Allowable - $8.678 KENALOG 40 mg/ml INJECTION (triamcinolone acetonide) Wellcare uses cookies. 211 0 obj
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If 2300.HI01-1 is not equal to "BK" or "ABK", the claim is rejected. 24f. If the NDC number was entered in theProcedurerecord: If the NDC number was entered in theEncounterrecord. Search and Lookup: ICD 10 Codes, CPT Codes, HCPCS Codes, ICD 9 Codes Toll Free Call Center: 1-877-696-6775. Page 1. If 2300.HI with HI01-1 = "ABK", all applicable diagnosis code HI segments must contain only ICD-10 qualifiers, otherwise the claim will reject. Comparing ICD-9-CM and ICD-10-PCS: Extraction . Wellcare's policy is to use a "qualifier" approach to transition our information systems to the ICD-10 standard. The Department may not cite, use, or rely on any guidance that is not posted incorporated into a contract. Box 21 - Procedure Code Qualifier 7 months ago Updated On both professional and institutional claims, the entity must disclose whether ICD-9 or ICD-10 codes are being utilized. 172 0 obj
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Scenario 1 Tips for Completing the UB-04 (CMS-1450) Form - UB04 Software, Inc. PROCEDURE-CODE-FLAG on the OT file should be coded 01 (CPT 4) or 06 (HCPCS) to indicate the code set used. CSC 732: "Information submitted inconsistent with billing guidelines." Receive 999A and 277CA with:
CSCC A7: "Acknowledgement /Rejected for Invalid Information"
Receive 999A and 277CA with:
Instead they are coded to the root operation . This document outlines the specifications for reporting diagnosis and procedure codes in T-MSIS claims files. CSC 255: "Diagnosis Code. When ISA15 = "P" and HI01-1 is not equal to "BJ", the claim rejects. Procedure Code Qualifier HCPC Codes. What percent of claims processed and paid claims are based on ICD codes? endstream
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Only one code set (either ICD-9 or ICD-10) is acceptable per claim.
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