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July 13, 2022, 02:14 EDT

Chapter : Billing Instructions (Hospital)

Updated: 5/21/2021

 

introduction

The purpose of this chapter is to explain the documentation procedures for billing the Virginia Medicaid Program.

Two major areas are covered in this chapter:

       General Information - This section contains information about the timely filing of claims, claim inquiries, and supply procedures.

       Billing Procedures - Instructions are provided on the completion of claim forms, submitting adjustment requests, and additional payment services.

Electronic Submission of Claims

Electronic billing using Electronic Data Interchange (EDI) is an efficient way to submit Medicaid claims. Providers use EDI software that enables the automated transfer of data in a specific format following specific data content rules directly to DMAS. For more information, go to https://vamedicaid.dmas.virginia.gov/edi.

The mailing address, phone number and fax number for the EDI program are:

EDI Coordinator

Virginia Medicaid Fiscal Agent

P.O. Box 26228

Richmond, Virginia 23260-6228

Phone: (866) 352-0766

Fax number: (888) 335-8460

The email to use for technical/web support for EDI is MESEDISupport@dmas.virginia.gov.

DIRECT DATA ENTRY (DDE)

Providers may submit Professional (CMS-1500), Institutional (UB-04) and Medicare Crossover claims using Direct Data Entry (DDE).  Providers also may make adjustments or void previously submitted claims through DDE. DDE is provided at no cost to providers. Paper claims submissions are not allowed except when requested by DMAS.

Providers must use the Medicaid Enterprise System (MES) Provider Portal to complete DDE. The MES Provider Portal can be accessed at https://vamedicaid.dmas.virginia.gov/provider.

Timely Filing

Federal regulations [42 CFR § 447.45(d)] require the initial submission of all Medicaid claims (including accident cases) within 12 months from the date of service. Only claims that are submitted within 12 months from the date of service are eligible for Federal financial participation. To request a waiver of timely filing requirements, providers billing electronically must submit a Claim Attachment Form (DMAS-3) with the appropriate attachments.

DMAS is not authorized to make payment on claims that are submitted late, except under the following conditions:

Retroactive Eligibility - Medicaid eligibility can begin as early as the first day of the third month prior to the month in which the individual makes application for benefits. All eligibility requirements must be met within that period for retroactive eligibility to be granted. In these instances, unpaid bills for that period may be submitted to DMAS as Medicaid claims.

Delayed Eligibility - Initial denials of an individual’s Medicaid eligibility application may be overturned or other actions may cause an eligibility determination to be delayed. DMAS may make payments for dates of service more than 12 months in the past when the claims are for an individual whose determination of eligibility was delayed.

It is the provider’s obligation to verify the individual’s Medicaid eligibility. The individual’s local department of social services will notify providers who have rendered care during a period of delayed eligibility. The notification will indicate notification of the delayed eligibility and include the Medicaid ID number, and the time span for which eligibility has been granted. The provider must submit a claim within 12 months from the date of the notification of the delayed eligibility. A copy of the “signed and dated” letter from the local department of social services indicating the delayed claim information must be attached to the claim.

Denied claims - Denied claims must be submitted and processed on or before 13 months from the date of the initial claim denial where the initial claim was filed according to the timely filing requirements. The procedures for resubmission are:

  • Complete invoice as explained in this billing chapter.
  • Attach written documentation to justify/verify the explanation. If billing electronically and waiver of timely filing is being requested, submit the claim with the appropriate attachments. (The DMAS-3 form is to be used by electronic billers for attachments. See exhibits).

Accident Cases - The provider may either bill DMAS or wait for a settlement from the responsible liable third party in accident cases. However, all claims for services in accident cases must be billed to DMAS within 12 months from the date of the service. If the provider waits for the settlement before billing DMAS and the wait extends beyond 12 months from the date of the service, DMAS shall make no reimbursement.

Other Primary Insurance - The provider must bill other insurance as primary.  However, all claims for services must be billed to DMAS within 12 months from the date of the service. If the provider waits for payment before billing DMAS and the wait extends beyond 12 months from the date of the service, DMAS will make no reimbursements. If payment is made from the primary insurance carrier after a payment from DMAS has been made, an adjustment or void should be filed at that time.

Other Insurance - The member can keep private health insurance and still be covered by Medicaid. The other insurance plan pays first. Having other health insurance does not change the co-payment amount that providers may collect from a Medicaid member. For members with a Medicare supplemental policy, the policy can be suspended with Medicaid coverage for up to 24 months while the member has Medicaid without penalty from their insurance company. The member must notify the insurance company within 90 days of the end of Medicaid coverage to reinstate the supplemental insurance.

Billing Invoices (Hospital)

The requirements for submission of hospital billing information and the use of the appropriate claim form or billing invoice are dependent upon the type of service being rendered by the provider and/or the billing transaction being completed.  Listed below is the billing invoice to be used:

  • Health Insurance Claim Form,  CMS-1450 (UB-04)

The requirement to submit claims on an original UB 04 claim form is necessary because the individual signing the form is attesting to the statements made on the reverse side of this form; therefore, these statements become part of the original billing invoice.

The submitter of this form understands that misrepresentation or falsification of essential information as requested by this form may serve as the basis for civil monetary penalties and assessments and may upon conviction include fines and/or imprisonment under federal and/or state law(s).

Medicaid reimburses providers for the coinsurance, copays and deductible amounts on Medicare claims for Medicaid members who are dually eligible for Medicare and Medicaid. However, the amount paid by Medicaid in combination with the Medicare payment will not exceed the amount Medicaid would pay for the service if it were billed solely to Medicaid.

Automated Crossover Claims Processing (Hospital)

Most claims for dually eligible members are automatically submitted to DMAS. The Medicare claims processor will submit claims based on electronic information exchanges between these entities and DMAS. As a result of this automatic process, the claims are often referred to as “crossovers” since the claims are automatically crossed over from Medicare to Medicaid.

To make it easier to match providers to their Virginia Medicaid provider record, providers are to use their National Provider Identification (NPI) Provider Number.  When a crossover claim includes a NPI Provider Number, the claim will be processed by DMAS using the NPI Provider Number.   In order for Medicare Crossover claims to be paid, the NPI number used on claims submitted to Medicare must be enrolled with Virginia Medicaid.   Failure to submit and enroll with Medicaid using your NPI will result in claims being denied.  Should providers not share their NPI, DMAS will not be able to process the claims nor be able to notify a provider of the denial.   Information on enrollment for the purpose of insuring Medicare claims are crossed over should go to the DMAS web page at: www.dmas.virginia.gov and click on the Provider Enrollment option.

Providing the appropriate NPI Provider Number on the original claim to Medicare will reduce the need for submitting follow-up paper claims.

DMAS will no longer attempt to match a Medicare provider number to a Medicaid provider number. If an NPI is submitted, DMAS will only use this number.

Requests for Billing Materials (Hospital)

Requests for Billing Materials

Health Insurance Claim Form  UB-04 CMS-1450

The UB-04 CMS-1450 is a universally accepted claim form that is required when billing DMAS for covered services. The form is available from form printers and the U.S. Government Printing Office. Specific details on purchasing these forms can be obtained by writing to the following address:

            U.S. Government Print Office

            Superintendent of Documents

            Washington, DC 20402

            (202) 512-1800 (Order and Inquiry Desk)

Note: The  UB-04 CMS-1450 will not be provided by DMAS.

Remittance/Payment Voucher (Hospital)

DMAS sends a check and remittance voucher with each weekly payment made by the Virginia Medical Assistance Program.  The remittance voucher is a record of approved, pended, denied, adjusted, or voided claims and should be kept in a permanent file for five (5) years.

The remittance voucher includes an address location, which contains the provider's name and current mailing address as shown in the DMAS' provider enrollment file.  In the event of a change-of-address, the U.S. Postal Service will not forward Virginia Medicaid payment checks and vouchers to another address.  Therefore, it is recommended that DMAS' Provider Enrollment and Certification Unit be notified in sufficient time prior to a change-of-address in order for the provider files to be updated.

Providers are encouraged to monitor the remittance vouchers for special messages since they serve as notifications of matters of concern, interest and information. For example, such messages may relate to upcoming changes to Virginia Medicaid policies and procedures; may serve as clarification of concerns expressed by the provider community in general; or may alert providers to problems encountered with the automated claims processing and payment system.

Ansi X12N 835 Health Care Claim Payment Advice (Hospital)

The Health Insurance Portability and Accountability Act (HIPAA) requires that Medicaid, comply with the electronic data interchange (EDI) standards for health care as established by the Secretary of Health and Human Services.  The 835 Claims Payment Advice transaction set is used to communicate the results of claim adjudication.  DMAS will make a payment with electronic funds transfer (EFT) or check for a claim that has been submitted by a provider (typically by using an 837 Health Care Claim Transaction Set).  The payment detail is electronically posted to the provider's accounts receivable using the 835.

In addition to the 835 the provider will receive an unsolicited 277 Claims Status Response for the notification of pending claims.  For technical assistance with certification of the 835 Claim Payment Advice please contact our fiscal agent, Conduent at (866) 352-0766.

Claim Inquiries and Reconsideration (Hospital)

Inquiries concerning covered benefits, specific billing procedures, or questions regarding Virginia Medicaid policies and procedures should be directed to:

Customer Services
Department of Medical Assistance Services

600 East Broad Street, Suite 1300
Richmond, VA 23219

A review of additional documentation may sustain the original determination or result in an approval or denial.

Telephone Numbers

1-804-786-6273 Richmond Area and out-of-state long distance
1-800-552-8627 In-state long-distance (toll-free)

Member verification and claim status may be obtained by telephoning:

1-800- 772-9996 Toll-free throughout the United States
1-800- 884-9730 Toll-free throughout the United States
1-804- 965-9732 Richmond and Surrounding Counties
1-804- 965-9733 Richmond and Surrounding Counties

Member verification and claim status may also be obtained by utilizing the Web-based Automated Response System. See Chapter I for more information.

Billing Procedures (Hospital)

Hospitals and other practitioners must use the appropriate claim form or billing invoice when billing the Virginia Medicaid Program for covered services provided to eligible Medicaid enrollees. Each enrollee's services must be billed on a separate form.

The provider should carefully read and adhere to the following instructions so that claims can be processed efficiently. Accuracy, completeness, and clarity are important. Claims cannot be processed if applicable information is not supplied, in correct national form and format, or is illegible. Completed claims should be mailed to:

Department of Medical Assistance Services

P.O. Box 27443

Richmond, Virginia 23261-7443

Or

Department of Medical Assistance Services

CMS Crossover

P. O. Box 27444

Richmond, Virginia 23261-7444

Electronic Filing Requirements (Hospital)

DMAS is fully compliant with 5010 transactions and will no longer accept 4010 transactions after March 30, 2012.

The Virginia MMIS will accommodate the following EDI transactions according to the specification published in the Companion Guide version 5010.

270/271           Health Insurance Eligibility Request/ Response Verification for Covered Benefits (5010)

276/277           Health Care Claim Inquiry to Request/ Response to Report the Status of a Claim (5010)

277                  Unsolicited Response (5010)

820                  Premium Payment for Enrolled Health Plan Members (5010)

834                  Enrollment/ Disenrollment to a Health Plan (5010)

835                  Health Care Claim Payment/ Remittance (5010)

837                  Dental Health Care Claim or Encounter (5010)

837                  Institutional Health Care Claim or Encounter (5010)

837                  Professional Health Care Claim or Encounter (5010)

NCPDP           National Council for Prescription Drug Programs Batch (5010)

NCPDP           National Council for Prescription Drug Programs POS (5010)

Although not mandated by HIPAA, DMAS has opted to produce an Unsolicited 277

transaction to report information on pended claims.

All 5010/D.0 Companion Guides are available on the web portal:

https://vamedicaid.dmas.virginia.gov/edi or contact EDI Support at 1-866-352-0766  or   dmasedisupport@dmas.virginia.gov.

Although not mandated by HIPAA, DMAS has opted to produce an Unsolicited 277 transaction to report information on pended claims.

For providers that are interested in receiving more information about utilizing any of the above electronic transactions, your office or vendor can obtain the necessary information at our fiscal agent’s website:  https://www.virginiamedicaid.dmas.virginia.gov.

Present on Admission Indicator (POA), Hospital Acquired Conditions (HAC) and Never Events

On all claims submitted by acute care inpatient hospital stays, DMAS requires the use of the POA indicators. Claims submitted without the appropriate indicator on the claim will be denied. Present on Admission is defined as the illness or condition present at the time the order for inpatient admission occurs – conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission. The POA indicator is assigned to the principal and secondary ICD diagnoses (as defined in Section II of the Official Guidelines for Coding and Reporting) and the External Cause of Injury Diagnosis codes. DMAS will follow the Present on Admission reporting guidelines as defined by the Department of Health and Human Services (DHHS).

  • The POA indicator is a required field on the claim and is to be indicated if:
  • The diagnosis was known at the time of admission, or
  • The diagnosis was clearly present, but not diagnosed, until after admission took place, or
  • Was a condition that developed during an outpatient encounter

Indicator Code Definition:

Y = Yes

N = No

U = No information in the record

W = Clinically undetermined

1 or blank = Exempt from POA reporting.

This code is used on the 837I and is the equivalent of a blank on the UB-04

CMS has a defined listing of ICD-diagnosis codes that are exempt from the requirement of a POA. DMAS has adapted these same diagnosis codes as exempt. For a complete listing of the exempt diagnosis codes, please refer to the Centers for Medicare and Medicaid (CMS) website at: http://www.cdc.gov/nchs/icd/icd10cm.htm Information related to submitting an electronic claim can be found at the DMAS website: https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/EDICompanionGuides.

Hospital Acquired Conditions (HACS)

Effective with claims received on or after January 1, 2010, DMAS implemented the Center for Medicare and Medicaid Services (CMS) Hospital Acquired Conditions (HAC) payment provision.

CMS has identified specific HACs that are associated with the Present on Admission (POA) indicator. POA indicators will be used in determining which diagnosis codes will be considered when assigning the APR-DRGs and will potentially affect the provider reimbursement amount. The diagnosis codes that are taken under consideration as HACs require a POA indicator to determine whether they will be included in the DRG Grouper. If the primary, secondary, or external diagnosis code has a POA indicator of N or U, and a HAC is present, that code will be excluded from the DRG grouper. Only those HACs with a POA code of ‘Y’ or ‘W’ will be included in the DRG grouper. If the POA indicator is a 1 or blank, and the diagnosis code is exempt from POA reporting as determined by CMS, that code will be included in the DRG grouper.

The Centers for Medicare and Medicaid (CMS) has a defined listing of ICD- diagnosis and procedure codes that are Hospital Acquired Conditions. DMAS has adapted these same diagnosis and procedure codes. For a complete listing of the codes, please refer to the Centers for Medicare and Medicaid Services (CMS) website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalA….

Effective for dates of service on or after July 1, 2012, DMAS will expand the HAC provision to inpatient psychiatric facilities, including freestanding EPSDT psychiatric hospitals and state mental hospitals; and inpatient rehabilitation hospitals. These changes are to comply with federal regulations related to the Affordable Care Act. 

These facilities are paid on a per-diem methodology and HAC reimbursement adjustments will be made using a day reduction schedule. The day reduction schedule will include all ICD- codes that qualify as HACs and the average length of stay for each diagnosis. Claims with an ICD-code identified as an HAC and a POA code of ‘N’ or ‘U’ will have their total length of stay reduced by the average length of stay for the hospital acquired diagnosis code. For psychiatric claims with a 21-day limit, the total length of stay will be calculated based on the days prior to any HAC reduction. The day reduction schedule is based on the Thomson Reuters single average length of stay for each diagnosis code identified as an HAC. In the event, the day-reduction creates a partial day(s), DMAS will round to nearest full day reduction.

New HAC Exclusion

In accordance with federal regulations in response to the Affordable Care Act, DMAS will exempt from HAC consideration, cases where the onset of a deep vein thrombosis (DVT) and/or pulmonary embolism (PE) occurs in pediatric or obstetric patients following a total knee or hip replacement procedure.

Never Events

Effective July 1, 2009, DMAS will also implement CMS’s guidelines related to Never Events. A Never Event is a serious preventable error in medical care. DMAS will not cover Never Events. CMS has identified three Never Events: wrong surgery on a patient, surgery on wrong body part and surgery on wrong patient. Whenever any of these events occurs with respect to a covered Medicaid member, the hospital shall immediately report such event to DMAS at the following address:

Supervisor, Payment Processing Unit

Division of Program Operation

Department of Medical Assistance Services

600 East Broad Street, Suite 1300

Richmond, Virginia 23219

If after notification, it has been found the hospital received payment from DMAS, the claim will be voided immediately. The hospital shall neither bill, nor seek to collect from, nor accept payment from DMAS or the member or the member’s family/legal guardian for such an event. Any deductible, co-payment or any other monies collected from the member or the member’s family/legal guardian related to this hospitalization shall be refunded immediately. The Hospital will cooperate fully with DMAS in any DMAS initiative designed to help analyze or reduce these preventable adverse events. Should payment of these events be discovered during an audit process by DMAS or their designated agent, the monies paid by DMAS will be retracted.

Utilization of Interim Bill Types (Hospital)

Effective with admissions on or after March 1, 2006, DMAS accepts interim HIPAA compliant bill types for hospitals, intermediate care facilities, nursing facilities, residential treatment facilities, and hospice.  This only affects the ‘3rd’ digit of the bill type for claims submitted by all provider types listed above. This does not change any other billing requirements. The third digit reflects the following:

  • 2 – first interim claim
  • 3 – subsequent interim claim(s)
  • 4 – final interim claim

This will affect the discharge status coding on the first and subsequent interim claims. Since these are interim claims, the discharge status must be ‘30’ – still a patient. For the final interim claim, the discharge status must reflect a discharge or transfer status. Refer to your appropriate National Uniform Billing Manual for additional discharge or transfer status codes.

Admission dates are not affected by the use of interim claim bill types, but should be consistent among all interim claims.

Note: Third digit ‘1’ indicates patient was admitted and discharged on this single claim.

Proper Procedure for Sending Checks for Claims Processing Errors

Do not send checks directly to DMAS when trying to refund the agency for claims processing errors. Providers are required to void and/or adjust their claims through the Virginia Medicaid Management Information System (VaMMIS) when they are associated with claims processing errors. If providers need further assistance, providers can also call the HELPLINE about how to process adjustments.

Once processed, adjustments or voids will be reflected on the next DMAS remittance advice, and any remaining payments will be adjusted accordingly. This process is designed to ensure provider claims are updated in a timely and accurate manner. All money paid by or submitted to DMAS must be associated with a corresponding claim. Failure to do so will result in inaccurate accounting and the potential for future adjustments and retractions once identified.

ClaimCheck/Correct Coding Initiative (CCI) (Hospital)

  • Effective June 3, 2013, DMAS implemented the Medicaid National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) and Medically Unlikely Edits (MUE) edits.  This implementation was in response to directives in the Affordable Care Act of 2010. These new edits will impact all Physicians, Laboratory, Radiology, Ambulatory Surgery Centers, and Durable Medical Equipment and Supply providers. Effective January 1, 2014, all outpatient hospital claims will be subject the NCCI edits through the EAPG claim processing.   Please refer to the Hospital Manual, Chapter 5 for details related to EAPG.  The NCCI/ClaimCheck edits are part of the daily claims adjudication cycle on a concurrent basis.  The current claim will be processed to edit history claims.  Any adjustments or denial of payments from the current or history claim(s) will be done during the daily adjudication cycle and reported on the providers weekly remittance cycle.  All NCCI/ClaimCheck edits are based on the following global claim factors:  same member, same servicing provider, same date of service or the date of service is within established pre- or post-operative time frame.  All CPT and HCPCS code will be subject to both the NCCI and ClaimCheck edits.  Upon review of the denial, the provider can re-submit a corrected claim. Any system edits related to timely filing, etc. are still applicable. 
  • PTP Edits:

CMS has combined the Medicare Incidental and Mutually Exclusive edits into a new PTP category. The PTP edits define pairs of CPT/HCPCS codes that should not be reported together. The PTP codes utilize a column one listing of codes to a column two listing of codes. In the event a column one code is billed with a column two code, the column one code will pay, the column two code will deny. The only exception to the PTP is the application of an accepted Medicaid NCCI modifier. Note: Prior to this implementation, DMAS modified the CCI Mutually Exclusive edit to pay the procedure with the higher billed charge. This is no longer occurring, since CMS has indicated that the code in column one is to be paid regardless of charge.

  • MUE Edits:

DMAS implemented the Medicaid NCCI MUE edits. These edits define for each CPT/HCPCS code the maximum units of service that a provider would report under most circumstances for a single member on a single date of service and by same servicing provider. The MUEs apply to the number of units allowed for a specific procedure code, per day. If the claim units billed exceed the per day allowed, the claim will deny.  With the implementation of the MUE edits, providers must bill any bilateral procedure correctly. The claim should be billed with one unit and the 50 modifier. The use of two units will subject the claim to the MUE, potentially resulting in a denial of the claim. Unlike the current ClaimCheck edit which denies the claim and creates a claim for one unit, the Medicaid NCCI MUE edit will deny the entire claim.

  • Exempt Provider Types

DMAS has received approval from CMS to allow the following provider types to be exempt from the Medicaid NCCI editing process. These providers are: Community Service Boards (CSB), Federal Health Center (FQHC),Rural Health Clinics (RHC), Schools and Health Departments.  These are the only providers exempt from the NCCI/editing process.  All other providers billing on the CMS 1500 will be subject to these edits. 

  • Service Authorizations:

DMAS has received approval from CMS to exempt specific CPT/HCPCS codes which require a valid service authorization.  These codes are exempt from the MUE edits however, they are still subject to the PTP and ClaimCheck edits.  

  • Modifiers:

Prior to this implementation, DMAS allowed claim lines with modifiers 24, 25, 57, 59 to bypass the CCI/ClaimCheck editing process. With this implementation, DMAS now only allows the Medicaid NCCI associated modifiers as identified by CMS for the Medicaid NCCI. The modifier indicator currently applies to the PTP edits. The application of this modifier is determined by the modifier indicator of “1”or “0” in the listing of the NCCI PTP column code. If the column one, column two code combination has a modifier indicator of “1”, a modifier is allowed and both codes will pay. If the modifier indicator is “0”, the modifier is not allowed and the column two code will be denied. The MUE edits do not contain a modifier indicator table on the edit table. Per CMS, modifiers may only be applied if the clinical circumstances justify the use of the modifier. A provider cannot use the modifier just to bypass the edit. The recipient’s medical record must contain documentation to support the use of the modifier by clearly identifying the significant, identifiable service that allowed the use of the modifier. DMAS or its agent will monitor and audit the use of these modifiers to assure compliance. These audits may result in recovery of overpayment(s) if the medical record does not appropriately demonstrate the use of the modifiers.

Modifiers that may be used under appropriate clinical circumstances to bypass an NCCI PTP edit include: E1 –E4, FA, F1 – F9, TA T1 – T9, LT, RT, LC, LD, RC, LM, RI, 24, 25, 57, 58, 78, 79, 27, 59, 91.  Modifiers 22, 76 and 77 are not Medicaid PTP NCCI approved modifiers. If these modifiers are used, they will not bypass the Medicaid PTP NCCI edits.

Billing Instructions Reference for Services Requiring Service Authorization

Please refer to the “Service Authorization” section in Appendix D of this manual.

Hospital-Based Physician Billing (Hospital)

Hospital-based physicians must submit separate billings to DMAS for their professional fees (components) utilizing the CMS-1500 (02-12) billing form. Combined billing of the professional fees on the hospital's invoice (UB-04 CMS-1450) is not allowed by DMAS except for authorized transplant claims. Please refer to Chapter V of the Physicians Manual.

Mother/Newborn Billing (Hospital)

All newborn enrollments are processed by Cover Virginia. Hospitals access an online web form to submit an electronic newborn DMAS-213 enrollment form. The online E-213 form is accessed through the VaMMIS provider portal. Once the provider logs into VaMMIS, a hyperlink is available in the Quick Links menu. When the child is enrolled a notice of action with the child’s new twelve digit Medicaid identification number is emailed to the hospital worker who submitted the E-213 form. This Medicaid identification number will be for billing purposes.

A DMAS-213 form may also be faxed to Cover Virginia. The DMAS-213 paper form for faxing is included in the “Exhibits” section at the end of the chapter. The mother/guardian will need to call the Cover Virginia Call Center to submit a telephonic DMAS-213 form for enrollment.

Claims for newborns must be billed under the newborn’s unique Medicaid identification number.  Claims for newborns born on or after January 1, 2000, are to be billed using any combination of revenue codes, and their claims will be reimbursed based on the DRG payment methodology. 

Claims for newborns born to a MCO enrolled mother at the time of birth must be sent to the mother’s MCO.  The MCO is responsible to cover the infant for the birth month plus two months.

Billing for Transplant Services (Hospital)

Reimbursement for organ transplants is a global fee that covers procurement costs, all hospital costs from admission to discharge for the transplant procedure, and total physician costs for all physicians providing services during the transplant hospital stay, including radiologists, pathologists, oncologists, surgeons, anesthesiologists, etc. The global fee does not include pre-and post-hospitalization for the transplant procedure, pre-transplant evaluation, or organ search. To ensure that reimbursement is calculated correctly, hospitals must include all physicians’ fees on the claim. Reimbursement shall be based on the global fee amount or the actual charges, should they be less than the global fee. Send the claims for the transplant procedure directly to:

Manager, Payment Processing Unit

Department of Medical Assistance Services

600 East Broad Street

Richmond, Virginia 23219

Organ transplants must be authorized prior to rendering the service. Service authorization requests must be submitted by fax to DMAS Medical Support Unit. The number is 804- 452-5450. The hospital admission for the transplant procedure will be authorized separately by KEPRO. The organ transplant must be authorized before the hospital admission can be authorized. See Hospital Manual, Appendix D.

Outpatient Hospital Preventable Emergency Room Claim Changes (Hospital)

Beginning with dates of service on or after July 1, 2020, the principal diagnosis code (locator code 67 on the UB-04) will be reviewed for all claims billed with Emergency Room (ER) CPT procedure codes 99281 through 99284. If the principal diagnosis code on the claim is contained in the Preventable Emergency Room Listing, see EXHIBITS at the end of this chapter, the final payment will be based on an all-inclusive EAPG payment weight for CPT 99281. All other procedures on the outpatient hospital claim are packaged into the all-inclusive payment for 99281-99284. DMAS calculated a weight of 0.3085 for 99281 claims with a preventable diagnosis based on the data from FY2017 used in rebasing for FY2020. The July 2020 general release of the Virginia EAPG software by 3M included a customization of the Virginia EAPG software that implemented this reimbursement policy for preventable ER hospital visits. There is no change in claims processing for claims with CPT code 99285.

DRG-Related Billing Changes (Hospital)

DMAS will process and pay claims by All Patient-Diagnosis Related Group (APR-DRG) payment methodology.  Proper coding of ICD diagnosis and procedure codes, as well as accurate and complete recording of all data elements that affect APR-DRG assignment, is very important to ensuring that the hospital is properly reimbursed.  DMAS has implemented the following DRG payment methodology adjustments:

  • Newborns
    • Must be billed under the newborn’s unique Medicaid identification number.
  • Split Billing
    • Will not be allowed on either the hospital or state fiscal year end.  The DRG part of reimbursement will recognize all services on the date of discharge, and the per diem part of reimbursement will accumulate all days to the discharge date for reimbursement and cost settlement purposes.
  • Transfers
    • Whenever a patient is transferred between a medical/surgical unit and a psychiatric unit of the same hospital or the focus of the principal diagnosis is changed from medical/surgical diagnosis to one that is psychiatric, the stay in the medical/surgical unit must be billed as an admission and discharge separate from the treatment stay in the psychiatric unit.  The medical surgical stay will be reimbursed under the DRG methodology as one distinct stay (discharge), while the days in the psychiatric unit will be reimbursed under the psychiatric per diem methodology.  In addition, billing for each medical/surgical and psychiatric admission must coincide with the appropriate ICD diagnosis code supporting the admission and the service authorization type for appropriate reimbursement.
    • A transfer case is a patient who is discharged from one hospital and admitted to another within five (5) calendar days with the same or similar diagnosis.
      • Effective with dates of admissions on or after July 1, 2020, a readmission to the same facility can be between six (6) to twenty (20) calendar days.
      • If the transfer­ring hospital reports the correct patient discharge status code, the transfer case will be identified in the weekly processing and paid correctly as a transfer. 
      • Implied Transfers
        • Transfer cases that are not identified through correct reporting of a patient discharge status code on the claim will be identified in the monthly APR-DRG case building process as “implied transfers.”
        • When implied transfers are identified, a DRG payment may have already been made to the transferring hospital.  This payment will be adjusted and a transfer per diem payment will be made. 
        • These transactions will be reported on the remittance following the monthly cycle that identified the implied transfer. 
        • The receiving hospital will receive the APR-DRG payment.
      • Transfer Reimbursement Example:
        • A member is admitted on 11/18/2020 and discharged on 11/22/2020 with a transfer discharge patient status of 02.  The APR-DRG of 133 with severity of illness (SOI) of 4, DRG Weight of 001.9025, and Average Length of Stay (ALOS) of 7.38 is assigned.
        • The reimbursement calculation for this admission with specific provider rates is $14,369.21 divided by ALOS (7.38) = $1,947.04 (per diem) times 4 day hospitalization = approved payment of $7,713.18.
  • Readmissions
    • A readmission occurs when a patient is discharged and returns to the same hospital within five (5) calendar days with the same or similar diagnosis. 
    • Effective with dates of admissions on or after July 1, 2020, the readmission to the same facility can be between six (6) to thirty (30) calendar days. These cases are con­sidered a single case rather than two.  Readmissions will be identified in the monthly APR-DRG processing cycle.  Often when this occurs, one or both claims will al­ready have been paid.  The payment of the first claim will be adjusted to reflect a payment for the combined case, and an adjustment will be made to the second claim reflecting a zero payment. 
    • For readmissions between six (6) and thirty (30) days, the first hospitalization will receive the original APR-DRG payment and the second hospitalization will pay initially, however during the monthly DMAS case build process, the second claim will be adjusted to pay 50% of the calculated payment as a standalone claim[1]. The corrected processing will recog­nize all the coding and charges from both claims for purposes of APR-DRG assign­ment and potential outlier determination.  These transactions will be reported on the re­mittance following the monthly cycle that identified the readmission.
    • Exclusions from the 6 to 30 day readmissions billing adjustments are:

           1.  Critical Access Hospital admissions:

           2.  Planned Readmissions:

Planned readmissions that will be excluded from the reimbursement reduction will be identified by using procedures and diagnoses identified by CMS as “always planned” and/or patient discharge status. If the always planned procedures and diagnoses are modified, DMAS will update them at the beginning of the fiscal year.

Identifying Always Planned Procedures and Diagnoses

The list of always planned procedures and diagnoses is based on CMS contracted research submitted by Yale New Haven Health Services Corporation Center for Outcomes Research and Evaluation. This research can be found at the following link under “Version 7.0 Readmission Hospital Wide Report.” The report is formally titled 2018 All-Cause Hospital Wide Measure Updates and Specifications Report – Hospital- Level 30-Day Risk-Standardized Readmission Measure – Version 7.0 and always planned procedures and diagnoses are listed in tables PR.1 and PR.2 (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/HospitalQualityInits/Downloads/Hospital-Wide-All-Cause-Readmission- Updates.zip)

Always Planned Procedures

CCS 64 – Bone marrow transplant (note that DMAS does not reimburse bone marrow transplants by APR-DRG)

CCS 105 – Kidney transplant

CCS 176 – Other organ transplantation (other than bone marrow, corneal or kidney) (note that DMAS does not reimburse transplants by APR-DRG except for kidney and corneal transplants)

ICD-10-PCS procedure codes corresponding to the identified AHRQ Clinical Classifications Software (CCS) categories can be found here (https://www.hcup- us.ahrq.gov/toolssoftware/ccs10/ccs_pr_icd10pcs_2020_1.zip).

For additional information on the AHRQ CCS for procedures, please visit the AHRQ Health Care Cost and Utilization Project website here (https://www.hcup- us.ahrq.gov/toolssoftware/ccs10/ccs10.jsp).

Always Planned Diagnoses

CCS 45 – Maintenance chemotherapy; radiology

CCS 254 – Rehabilitation care; fitting of prostheses; and adjustment of devices.

ICD-10-CM diagnoses codes corresponding to the identified AHRQ CCS categories can be found here (https://www.hcup- us.ahrq.gov/toolssoftware/ccsr/DXCCSR-vs-Beta-CCS-Comparison.xlsx). Go to

the tab labeled “ICD-10-CM Code Detail” and look up the Beta Version CCS Category for CCS 45 and 254 to identify associated ICD-10-CM codes.

Patient Discharge Status on the Initial Admission

In addition to excluding readmissions associated with always planned procedures and diagnoses, DMAS will exclude readmissions following an initial admission where the patient had a discharge status of >81. Patient discharge status codes >81 indicate that the patient is being discharged or transferred with the expectation of a planned acute care hospital inpatient readmission. Refer to Locator 17 of the UB instruction further in this chapter.  This criterion is intended to capture other planned admissions that are not included in the always planned procedures and diagnoses lists. It is important for hospital discharge staff to code this patient discharge status indicator correctly in order to identify these planned readmissions.

                       3. Obstetrical Admissions:

DMAS will use the following principal diagnosis codes to identify an obstetrical readmission excluded from the reduction policy.

    • ICD-10-CM - O00-O088 - Pregnancy with abortive outcome
    • ICD-10-CM - 009-00993 –Supervision of high risk pregnancy
    • ICD-10-CM - O10-O169 - Edema, proteinuria and hypertensive disorders in pregnancy, childbirth and the puerperium
    • ICD-10-CM - O20-O2993 - Other maternal disorders predominantly related to pregnancy
    • ICD-10-CM - O30-O481 - Maternal care related to the fetus and amniotic cavity and possible delivery problems
    • ICD-10-CM - O60-O779 - Complications of labor and delivery
    • ICD-10_CM – 080-092.79 - Encounter for delivery
    • ICD-10-CM - O94-O9A.53 - Other obstetric conditions, not elsewhere classified

 

4. Discharges against medical advice:

DMAS will use the following discharge status code on the first admission to exclude the readmission from a reimbursement reduction.

    • 07 - Left Against Medical Advice
  • Medicaid Expansion Partial-Stay Eligibility Discharges:
    • CMS has provided Federal Policy guidance to states as stated in "Medicaid and CHIP FAQs: Implementing Hospital presumptive Eligibility Programs" from January 2014 in Question 26  on the appropriate interpretation of 42 CFR §435.915 in regards to member eligibility at the time services are provided.  CMS instructed DMAS that there is no allowance of payment for ineligible dates of service regardless of the reason for ineligibility, such as: member is in a benefit program that does not cover inpatient acute care, or the coverage for Medicaid Expansion begins within the hospitalization from and through dates.  DMAS will reimburse ONLY the portion of the hospitalization that the member is eligible for based on a per diem methodology.
    • Example:
      • Member is admitted on 12/27/2020 and discharged on 01/11/2021 which is a 15 day hospitalization:
      • The patient had no Medicaid eligibility for dates of service 12/27/2021 through 12/31/2020. The patient became eligible for Medicaid Expansion on 01/01/2021 so the patient had 10 days of eligibility out of a 15 day stay
      • The APR-DRG assigned for the stay was 264 with a Severity of Illness (SOI) of 3 and a DRG Weight of 1.9822.
      • Total Medicaid hospital APR-DRG reimbursement for the entire stay would be $13,231.12. For partial stay eligibility the total APR-DRG reimbursement is only for the days that the patient had Medicaid eligibility. The total reimbursement ($13,231.12) is  divided by 15 (total days of the stay) to get a per diem rate of $882.07. The per diem rate is then multiplied by the number of days the patient had eligibility  ($882.07 x 10) to get the Medicaid partial-stay payment of $8,820.70.
      • The remittance advice will indicate that 15 days were billed and 5 days were cutback. There will be an error message code of #601 indicating Medicaid Expansion Cutback. 
    • Providers are to bill the complete length of stay regardless of eligibility (from admission through discharge) and utilize the appropriate bill types (111, 112, 113, 114) when submitting claims. 
    • Providers are responsible for obtaining the necessary service authorizations for the first eligible day.
    • Provider inquiries related to the processing of Medicaid Expansion Hospitalizations may send them to MedicaidExpansion@DMAS.virginia.gov
  • APR-DRG weights and rates are available on the DMAS website at: https://www.dmas.virginia.gov/#/hospitalrates
 

[1] Managed Care Organizations may choose to adjust the 2nd claim immediately and not part of a monthly process.

 

 

 

Long Acting Reversible Contraceptives (LARC) (Hospital)

Effective for dates of service on or after January 1, 2017, DMAS is updating its policy to include reimbursement for LARCs provided after delivery in inpatient hospitals.  The reimbursement for the LARC will be considered a separate payment and will not be included in the Diagnostic Related Group (DRG) reimbursed to the Facility. 

This information addresses LARCs inserted or implanted after delivery in inpatient hospitals only.   The billing process for the inpatient LARC insertion differs dependent on the member’s coverage. 

LARC Device J Codes to be covered for separate facility reimbursement at inpatient hospitals are:

IUD:                  

    • J7296 – Kyleena
  • J7297 – Liletta
  • J7298 – Mirena
    • J7301 – Skyla
    • J7300 – Paragard

Implant

    • J7307 – Implanon/Nexplanon

Prior authorization is not required on any of the above J codes.

Billing Process #1 for Medicaid and FAMIS Fee For Service, Virginia Premier Health Plan, Aetna Better Health of Virginia, Anthem HealthKeepers, Magellan CompleteCare of VA, Optima Health Plan, and United HealthCare Community Plan:

In order to receive a LARC device payment that is separate from the DRG payment, hospitals will need to submit two UB-04 claims.  The facility will receive two separate payments.  The inpatient claim (bill type 011x) will be for the inpatient hospitalization and will be reimbursed via DRG.  The second claim will be an outpatient claim (bill type 013x) for the LARC device only. 

The following information is required on the outpatient claim: the applicable pharmaceutical revenue code (025x and/or 063x), LARC device J code (listed above) and National Drug Code (NDC) for the LARC device.  The claim will be reimbursed via the current DMAS EAPG payment methodology for Fee-for-Service members.  The health plans will make a separate payment that is at least the DMAS Fee-for-Service rates for the J codes.  Hospitals participating in the 340B drug pricing program must conform to the program’s billing requirements.

Billing Process #2 for Anthem HealthKeepers Plus and Optima Family Care Medicaid and FAMIS Health Plans:

Hospital Billing

Facilities will bill all charges including those for the LARC on one inpatient claim (011x).  The bill must contain the revenue code 0250, LARC device J code.   The J codes listed above are to be used on these claims.

Fraudulent Claims (Hospital)

Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.  It includes any act that constitutes fraud under applicable federal or state law.

Since payment of claims is made from both state and federal funds, submission of false or fraudulent claims, statements, or documents or the concealment of a material fact may be prosecuted as a felony in either federal or state court.  DMAS maintains records for identifying situations in which there is a question of fraud and refers appropriate cases to the Office of the Attorney General for Virginia, the United States Attorney General, or the appropriate law enforcement agency.

Provider Fraud (Hospital)

The provider is responsible for complying with applicable state and federal laws and regulations and the requirements set forth in this manual. If electronically submitting claims or using electronic submission, use EDI format Version 5 prior to May 31, 2003. For electronic submissions on or after June 3, 2003, use EDI transactions specifications published in the ASC X12 Implementation Guides version 4040A1. The provider is also responsible for ensuring that all employees are likewise informed of these regulations and requirements. The provider certifies by his or her signature or the signature of his or her authorized agent on each invoice that all information provided to DMAS is true, accurate, and complete. Although claims may be prepared and submitted by an employee, providers will still be held responsible for ensuring their completeness and accuracy. Repeated billing irregularities or possible unethical billing practices by a provider should be reported to the following address, in writing, and with appropriate supportive evidence.

Supervisor, Provider Review Unit

Program Integrity Division

Department of Medical Assistance Services

600 East Broad Street, Suite 1300

Richmond, Virginia 23219

Investigations of allegations of provider fraud are the responsibility of the Medicaid Fraud Control Unit in the Office of the Attorney General for Virginia. Provider records are available to personnel from that unit for investigative purposes. Referrals are to be made to:

Director, Medicaid Fraud Control Unit

Office of the Attorney General

900 E. Main Street, 5th Floor

Richmond, Virginia 23219

Member Fraud (Hospital)

Allegations about fraud or abuse by members are investigated by the Member Audit Unit of the Department of Medical Assistance Services. The unit focuses primarily on determining whether individuals misrepresented material facts on the application for Medicaid or failed to report changes that, if known, or both, would have resulted in ineligibility. The unit also investigates incidences of card sharing and prescription forgeries.

If it is determined that benefits to which the individual was not entitled were approved, corrective action is taken by referring individuals for criminal prosecution, civil litigation, or establishing administrative overpayments and seeking recovery of misspent funds.

Under provisions of the State Plan for Medical Assistance, DMAS must sanction an individual who is convicted of Medicaid fraud by a court. That individual will be ineligible for Medicaid for a period of twelve months beginning with the month of fraud conviction.

Referrals should be made to:

Supervisor, Member Auditing Unit

Program Integrity Division

Department of Medical Assistance Services

600 East Broad Street, Suite 1300

Richmond, Virginia 23219

Molecular Pathology (Hospital)

DMAS covers Current Procedure Terminology (CPT) codes in the range 81200-81599 and S3854. Effective with dates of service on or after May 01, 2014, codes in this range will no longer require a service authorization.

DMAS considers genetic testing medically necessary to establish a molecular diagnosis of an inheritable disease when all of the following are met:

  • The member must display clinical features, or
  • Is at direct risk of inheriting the mutation in question (pre-symptomatic); and
  • The result of the test will directly impact the treatment being delivered to the member.

It is up to the primary physician to ensure the aforementioned criteria are met for coverage of these tests. If these criteria are not met on retrospective review of claims by DMAS, then the payment for the physician, hospital and all related laboratory claims will be recovered.

Billing Instructions: Instructions for Completing the UB-04 CMS-1450 Claim Form (Hospital)

                                   INSTRUCTIONS FOR COMPLETING THE UB-04 CMS-1450 CLAIM FORM

 

Locator                                                                           Instructions

 

1

Provider Name, Address, Telephone

Required

Provider Name, Address, Telephone - Enter the provider's name, complete mailing address and telephone number of the provider that is submitting the bill and which payment is to be sent.

Line 1. Provider Name

Line 2. Street Address

Line 3. City. State, and  9 digit Zip Code

Line 4. Telephone; Fax; Country Code

 

 

 

 

2

Pay to Name & Address

Required if Applicable

Pay to Name & Address - Enter the address of the provider where payment is to be sent, if different than Locator 1.

NOTE:  DMAS will need to have the 9 digit zip code on line three, left justified for adjudicating the claim if the provider has provided only one NPI and the servicing provider has multiple site locations for this service. 

 

 

 

3a

Patient Control Number

Required

Patient Control Number - Enter the patient’s unique financial account number which does not exceed 20 alphanumeric characters.

 

 

 

 

3b

Medical/Health Record

Required

Medical/Health Record - Enter the number assigned to the patient’s medical/health record by the provider.  This number cannot exceed 24 alphanumeric characters.

 

 

 

4

Type of Bill Required

Type of Bill - Enter the code as appropriate.  Valid codes for Virginia Medicaid are:

 

 

 

 

 

0111    Original Inpatient Hospital Invoice

 

 

0112    Interim Inpatient Hospital Claim Form*

 

 

0113    Continuing Inpatient Hospital Claim Invoice*

 

 

0114    Last Inpatient Hospital Claim Invoice*

 

 

0117    Adjustment Inpatient Hospital Invoice

 

 

0118    Void Inpatient Hospital Invoice

 

 

0131    Original Outpatient Invoice

 

 

0137    Adjustment Outpatient Invoice

 

 

0138    Void Outpatient Invoice

 

 

These below are for Medicare Crossover Claims Only

 

 

0721    Clinic - Hospital Based or Independent Renal Dialysis Center

 

 

0727    Clinic - Adjustment-Hospital Based or Independent Renal Dialysis Center

 

 

0728  Clinic - Void - Hospital Based or Independent Renal Dialysis Center

 

 

 

 

 

* The proper use of these codes (see the National Uniform Billing Manual) will enable DMAS to reassemble inpatient acute medical/surgical hospital cycle-billed claims to form DRG cases for purposes of DRG payment calculations and cost settlement.

 

 

 

  5

Federal Tax Number

Not Required

Federal Tax Number - The number assigned by the federal government for tax reporting purposes

 

 

 

6

Statement Covered Period

Required

Statement Covered Period - Enter the beginning and ending service dates reflected by this invoice (include both covered and non-covered days).  Use both "from" and "to" for a single day.

 

For hospital admissions, the billing cycle for general medical surgical services has been expanded to a minimum of 120 days for both children and adults except for psychiatric services.  Psychiatric services for adults’ remains limited to the 21 days.  Interim claims (bill types 0112 or 0113) submitted with less than 120 day will be denied.  Bill type 0111 or 0114 submitted with greater than 120 days will be denied.

Outpatient:  spanned dates of service are allowed in this field.  See block 45 below.

 

 

 

 

7

Reserved for assignment by the NUBC

Reserved for assignment by the NUBC

NOTE:  This locator on the UB 92 contained the covered days of care.  Please review locator 39 for appropriate entry of the covered and non-covered days.

 

 

 

8

Patient Name/Identifier

Required

Patient Name/Identifier - Enter the last name, first name and middle initial of the patient on line b. Use a comma or space to separate the last and first name.

 

 

 

 

9

Patient Address

Patient Address - Enter the mailing address of the patient.

  1. Street address
  2. City
  3. State
  4. Zip Code (9 digits)
  5. Country Code if other than USA

 

 

 

 

 

10

Patient Birthdate

Required

Patient Birthdate – Enter the date of birth of the patient.

 

 

 

11

Patient Sex

Required

Patient Sex – Enter the sex of the patient as recorded at admission, outpatient or start of care service. M = male; F = female and U = unknown

 

 

 

12

Admission/Start of Care

Required

Admission/Start of Care – The start date for this episode of care.  For inpatient services, this is the date of admission.  For all other services, the date the episode of care began.

 

 

 

 

13

 

Admission Hour

Required

Admission Hour Enter the hour during which the patient was admitted for inpatient or outpatient care.  Note: Military time is used as defined by NUBC.

 

 

 

14

 

Priority (Type) of Visit

Required

 

Priority (Type) of Visit – Enter the code indicating the priority of this admission/visit.  Appropriate codes accepted by DMAS are:

 

Code

Description

1

Emergency – patient requires immediate intervention for severe, life threatening or potentially disabling

condition

2

Urgent – patient requires immediate attention for

the care and treatment of physical or mental

disorder

3

Elective – patient’s condition permits adequate

time to schedule the services

4

Newborn

5

Trauma – Visit to a licensed or designated by the

state or local government trauma center/hospital

and involving a trauma activation

9

Information not available

 

 

 

 

15

Source of Referral for Admission or Visit

Required

 

Source of Referral for Admission or Visit Enter the code indicating the source of the referral for this admission or visit.

Note: Appropriate codes accepted by DMAS are:

 

Code:

Description

1

Physician Referral

2

Clinic Referral

4

Transfer from Another Acute Care Facility

5

Transfer from a Skilled Nursing Facility

6

Transfer from Another Health Care Facility (long

term care facilities, rehabilitative and psychiatric

facility)

7

Emergency Room

8

Court/Law Enforcement - Admitted Under

Direction of a Court of Law, or Under Request

of Law Enforcement Agency

9

Information not available

D

Transfer from Hospital Inpatient in the Same

Facility Resulting in a Separate Claim to the

Payer

 

 

 

 

16

Discharge Hour

Required

Discharge Hour – Enter the code indicating the discharge hour of the patient from inpatient care.  Note: Military time is used as defined by NUBC

 

 

 

 

17

Patient Discharge Status

Required

 

Patient Discharge Status – Enter the code indicating the disposition or discharge status of the patient at the end service for the period covered on this bill (statement covered period, locator 6).  Note: If the patient was a one-day stay, enter code "01". Appropriate codes accepted by DMAS are:

Code

Description

01

Discharged to Home

02

Discharged/transferred to Short term General

Hospital for Inpatient Care

03

Discharged/transferred to Skilled Nursing Facility

04

Discharged/transferred to Intermediate Care Facility

05

Discharged/transferred to Another Facility not

Defined Elsewhere

06

Discharged/transferred to home under care of organized home health service

07

Left Against Medical Advice or Discontinued Care

20

Expired

30

Still a Patient

50

Hospice – Home

51

Hospice – Medical Care Facility

61

Discharged/transferred to Hospital Based

Medicare Approved Swing Bed

62

Discharged/transferred to an Inpatient Rehabilitation

Facility

63

Discharged/transferred to a Medicare Certified

Long Term Care Hospital

64

Discharged/transferred to Nursing Facility

Certified under Medicaid but not Medicare

65

Discharged/transferred to Psychiatric Hospital of

Psychiatric Distinct Part Unit of Hospital

66

Discharged/Transferred to a Critical Access Hospital

(CAH)

81

Discharged to Home or Self Care with a Planned Acute Care Hospital Inpatient Readmission

82

Discharge/Transfer to a Short Term General Hospital for Inpatient Care with a Planned Acute Care Hospital Inpatient Readmission

83

Discharged/Transferred to a Skilled Nursing Facility (SNF) with Medicare Certification with a Planned Acute Care Hospital Inpatient Readmission

84

Discharged/Transferred to a Facility that Provides Custodial or Supportive Care with a Planned Acute Care Hospital Inpatient Readmission

85

Discharged/transferred to a Designated Cancer Center or Children’s Hospital with a Planned Acute Care Hospital Inpatient Readmission

86

Discharged/ Transferred to Home Under Care of Organized Home Health Service in Anticipation of Covered Skilled Care with a Planned Acute Care Hospital Inpatient Readmission

87

Discharged/ Transferred to Court/Law Enforcement with a Planned Acute Care Hospital Inpatient Readmission

88

Discharged/Transferred to a Federal Health Care Facility with a Planned Acute Care Hospital Inpatient Readmission

89

Discharged/Transferred to a Hospital-based Medicare Approved Swing Bed with a Planned Acute Care Hospital Inpatient Readmission

90

Discharged/Transferred to an Inpatient Rehabilitation Facility (IRF) including Rehabilitation Distinct Part Units of a Hospital with a Planned Acute Care Hospital Inpatient Readmission

91

Discharged/transferred to a Medicare Certified Long Term Care Hospital with a Planned Acute Care Hospital Inpatient Readmission

92

Discharged/Transferred to a Nursing Facility Certified Under Medicaid but not Certified Under Medicare with a Planned Acute Care Hospital Inpatient Readmission

93

Discharged/Transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a Hospital with a Planned Acute Care Hospital Inpatient Readmission

94

Discharges/Transferred to a Critical Access Hospital (CAH) with a Planned Acute Care Hospital Inpatient Readmission

95

Discharged/Transferred to Another Type of Health Care Institution not Defined Elsewhere in this Code List with a Planned Acute Care Hospital Inpatient Readmission

 

 

 

 

 

 

18 through 28

Condition Codes

Required if applicable

 

Condition Codes – Enter the code(s) in alphanumeric sequence used to identify conditions or events related to this bill that may affect adjudication.  Note: DMAS limits the number of condition codes to maximum of 8 on one claim.  

These codes are used by DMAS in the adjudication of claims:

Code

Description

39

Private Room Medically Necessary

40

Same Day Transfer

A1

EPSDT

A4

Family Planning

A5

Disability

A7

Inducted Abortion Danger to Life

AA

Abortion Performed due to Rape

AB

Abortion Performed due to Incest

AD

Abortion Performed due to a Life Endangering Physical Condition

AH

Elective Abortion

AI

Sterilization

 

 

29

Accident State

 

Accident State – Enter if known the state (two digit state abbreviation) where the accident occurred.

 

 

 

30

Crossover Part A Indicator

Note:  DMAS is requiring for Medicare Part A crossover claims that the word “CROSSOVER” be in this locator

31 through 34

Occurrence Code and Dates

Required if applicable

Occurrence Code and Dates – Enter the code and associated date defining a significant event relates to this bill.  Enter codes in alphanumeric sequence.

 

 

 

 

35 through 36

Occurrence Span Code and Dates

Required if applicable

Occurrence Span Code and Dates – Enter the code and related dates that identify an event that relating to the payment of the claim.  Enter codes in alphanumeric sequence.

 

 

 

 

37

TDO or ECO Indicator

Required if applicable

 

Note:  DMAS is requiring that for claims to be processed by the Temporary Detention Order (TDO) or by Emergency Custody Order (ECO) program, providers will enter TDO or ECO in this locator.

 

 

 

 

38

Responsible Party Name and Address

Responsible Party Name and Address – Enter the name and address of the party responsible for the bill

 

 

 

39 through 41

Value codes and Amount

Required

 

Value Codes and Amount - Enter the appropriate code(s) to relate amounts or values to identify data elements necessary to process this claim.

Note:  DMAS will be capturing the number of covered or non-covered day(s) or units for inpatient and outpatient service(s) with these required value codes:

  1. Enter the number of covered days for inpatient hospitalization or the number of days for re-occurring outpatient claims.
  2. Enter the number of non-covered days for inpatient hospitalization

 

Note: The format is digit: do not format the number of covered or non-covered days as dollar and cents

 

AND One of the following codes must be used to indicate the coordination of third party insurance carrier benefits:

  1.      No Other Coverage
  2.      Billed and Paid (enter amount paid by  primary carrier)
  1.            Billed Not Covered/No Payment

 

For Part A Medicare Crossover Claims, the following codes must be used with one of the third party insurance carrier codes from above:

      A1           Deductible from Part A

      A2           Coinsurance from Part A   

 Other codes may also be used if applicable.

 

The a, b, or c line containing this above information should Cross

Reference to Payer Name (Medicaid or TDO) in Locator 50 A, B, C.

 

 

 

 

42

Revenue Code

Required

 

Revenue Codes - Enter the appropriate revenue code(s) for the service provided.  Note:

  • Revenue codes are four digits, leading zero, left justified and should be reported in ascending numeric order,
  • Claims with multiple dates of services should indicate the date of service of each procedure performed on the revenue line,
  • DMAS has a limit of five pages for one claim,
  • The Total Charge revenue code (0001) should be the last line of the last page of the claim, and
  • See the Revenue Codes list under “Exhibits” at the end of this chapter for approved DMAS codes. 

       

 

 

 

43

Revenue  Description

Required

Revenue Description - Enter the standard abbreviated description of the related revenue code categories included on this bill.

● For Outpatient Claims, when billing for Revenue codes 0250-0259 or 0630-0639,  you must enter the NDC qualifier of N4, followed by the 11-digit NDC number, and the unit of measurement followed by the metric decimal quantity or unit.  Do not enter a space between the qualifier and NDC.  Do not enter hyphens or spaces within the NDC.  The NDC number being submitted must be the actual number on the package or container from which the medication was administered.

 

Unit of Measurement Qualifier Codes:

F2 – International Units

GR – Gram

ML – Milliliter

UN – Unit

 

Examples of NDC quantities for various dosage forms as follows:

    1. Tablets/Capsules – bill per UN
    2. Oral Liquids – bill per ML
    3. Reconstituted (or liquids) injections – bill per ML
    4. Non-reconstituted injections (I.E. vial of Rocephin powder) – bill as UN (1 vial = 1 unit)
    5. Creams, ointments, topical powders – bill per GR
    6. Inhalers – bill per GR

Any spaces unused for the quantity should be left blank

 

 

 

44

HCPCS/Rates/

HIPPS Rate Codes

Required (if applicable)

Modifier

HCPCS/Rates/HIPPS Rate Codes - Inpatient:  Enter the accommodation rate.  For Ambulatory Surgical Centers, enter the CPT or HCPCS code on the same line that the revenue code 0490 is entered. 

Outpatient:  For outpatient claims, the applicable HCPCS/CPT procedure code must appear in this locator with applicable modifiers..  Invalid CPT/HCPCS codes will result in the claim being denied. Providers participating in the 340B drug discount program must submit each drug line with modifier UD.

 

 

 

45

Service Date

Required

Service Date - Enter the date the outpatient service was provided.  Outpatient: Each line must have a date of service.  Claims with multiple dates of service must indicate the date of service of each procedure performed on the corresponding revenue line.  To be separately reimbursed for each visit- example chemotherapy, dialysis, or therapy visits- each revenue line should include the date of service for these series billed services.

 

 

 

 

46

Service Units

Required

Service Units - Inpatient:  Enter the total number of covered accommodation days or ancillary units of service where appropriate.

Outpatient:  Enter the unit(s) of service for physical therapy, occupational therapy, or speech-language pathology visit or session (1 visit = 1 unit).  Enter the HCPCS units when a HCPCS code is in locator 44.  Observation units are required.

 

 

 

47

Total Charges

Required

Total Charges - Enter the total charge(s) for the primary payer pertaining to the related revenue code for the current billing period as entered in the statement covers period.  Total charges include both covered and non-covered charges.  Note:  Use code “0001” for TOTAL.

 

 

 

48

Non-Covered Charges

Required if applicable

Non-Covered Charges - To reflect the non-covered charges for the primary payer as it pertains to the related revenue code.

 

 

 

49

Reserved

Reserved for Assignment by the NUBC.

50

Payer Name A-C.

Required

Payer Name - Enter the payer from which the provider may expect some payment for the bill.

 

 

 

 

 

A     Enter the primary payer identification.

 

 

B     Enter the secondary payer identification, if appli­cable.

 

 

C     Enter the tertiary payer if applicable.

 

 

 

 

 

When Medicaid is the only payer, enter "Medicaid" on Line A.  If Medicaid is the secondary or tertiary payer, enter on Lines B or C.  This also applies to the Temporary Detention and Emergency Custody Order claims.

 

 

 

51

Health Plan Identification Number A-C

Health Plan Identification Number - The number assigned by the health plan to identify the health plan from which the provider might expect payment for the bill. 

NOTE:  DMAS will no longer use this locator to capture the Medicaid provider number.  Refer to locators 56 and 57

 

 

 

52

Release of Information Certification Indicator A-C

Release of Information Certification Indicator - Code indicates whether the provider has on file a signed statement (from the patient or the patient’s legal representative) permitting the provider to release data to another organization.

 

53

Assignment of Benefits Certification Indicator A-C

 

Assignment of Benefits Certification Indicator - Code indicates provider has a signed form authorizing the third party payer to remit payment directly to the provider.

 

54

Prior Payments – Payer A,B,C

Required

(if applicable)

Prior Payments Payer – Enter the amount the provider has received (to date) by the health plan toward payment of this bill.

 

 

NOTE:  Long-Term Hospitals and Nursing Facilities:  Enter the patient pay amount on the appropriate line (a-c) that is showing Medicaid as the payer in locator 50.  The amount of the patient pay is  obtained via either Medicall or ARS.  See Chapter I for detailed information on Medicall and ARS.

 

 

 

 

 

DO NOT ENTER THE MEDICAID COPAY AMOUNT

 

 

 

55

Estimated Amount Due A,B,C,

 

Estimated Amount Due – Payer – Enter the amount by the provider to be due from the indicated payer (estimated responsibility less prior payments).

56

NPI

Required

National Provider Identification – Enter your NPI. 

 

 

 

 

57A through C

Other Provider Identifier

Required ( if applicable)

Other Provider Identifier - DMAS will not accept claims received with the legacy Medicaid number in this locator. For providers who are given an Atypical Provider Number (API), this is the locator that will be used. Enter the provider number on the appropriate line that corresponds to the member name in locator 50.

 

 

 

58

Insured’s Name

A-C Required

INSURED'S NAME - Enter the name of the insured person covered by the payer in Locator 50.  The name on the Medicaid line must correspond with the enrollee name when eligibility is verified. If the patient is covered by insurance other than Medicaid, the name must be the same as on the patient's health insurance card.

 

 

 

 

 

      Enter the insured's name used by the primary payer identified on Line A, Locator 50.

 

 

 

 

 

      Enter the insured's name used by the secondary payer identified on Line B, Locator 50.

 

 

 

 

 

      Enter the insured's name used by the tertiary payer identified on Line C, Locator 50.

59

Patient’s Relationship to Insured A-C Required

 

Patient’s Relationship to Insured - Enter the code indicating the relationship of the insured to the patient.  Note:  Appropriate codes accepted by DMAS are:

Code:

Description:

01

Spouse

18

Self

19

Child

21

Unknown

39

Organ Donor

40

Cadaver Donor

53

Life Partner

G8

Other Relationship

 

 

 

 

60

Insured’s Unique Identification A-C Required

Insured’s Unique Identification - For lines A-C, enter the unique identification number of the person insured that is assigned by the payer organization shown on Lines A-C, Locator 50.  NOTE:  The Medicaid member identification number is 12 numeric digits.

 

 

 

61

(Insured) Group Name A-C

 

(Insured) Group Name - Enter the name of the group or plan through which the insurance is provided.

62

Insurance Group Number A-C

 

Insurance Group Number - Enter the identification number, control number, or code assigned by the carrier/administrator to identify the group under which the individual is covered.

 

 

 

 

63

Treatment Authorization Code

Required (if applicable)

Treatment Authorization Code - Enter the 11 digits service authorization number assigned for the appropriate inpatient and outpatient services by Virginia Medicaid.

Note:  The 15 digit TDO or ECO order number from the pre-printed form is to be entered in this locator.

 

 

 

 

64

Document Control Number (DCN)

Required for adjustment and void claims

Document Control Number – The control number assigned to the original bill by Virginia Medicaid as part of their internal claims reference number.  Note:  This locator is to be used to place the original Internal Control Number (ICN) for claims that are being submitted to adjust or void the original PAID claim. 

 

 

 

65

Employer Name (of the Insured) A-C

 

Employer Name (of the Insured) - Enter the name of the employer that provides health care coverage for the insured individual identified in Locator 58.

 

 

 

66

Diagnosis and Procedure Code Qualifier

Required

Diagnosis and Procedure Code Qualifier (ICD Version Indicator) – The qualifier that denotes the version of the International Classification of Diseases.  Note: DMAS will only accept a 9 or 0 in this locator.  9= ICD-9-CM – Dates of service through 9/30/15, 0=ICD-10-CM – Dates of service on and after 10/1/15.”

 

 

 

 

67

Principal Diagnosis Code

Required

Principal Diagnosis Code - Enter the ICD diagnosis code that describes the principal diagnosis (i.e., the condition established after study to chiefly responsible for occasioning the admission of the patient for care). NOTE:  Special instructions for the Present on Admission indicator below.  DO NOT USE DECIMALS.

 

 

 

67 &

67A-Q

Present on Admission (POA) Indicator

Required

Present on Admission (POA) Indicator –  The locator for the POA is directly after the ICD diagnosis code in the red shaded field and is required for the Principal Diagnosis and the Secondary Diagnosis code .  The applicable POA indicator for the principal and any secondary diagnosis is to be indicated if:

  • the diagnosis was known at the time of admission, or
  • the diagnosis was clearly present, but not diagnosed, until after admission took place or
  • was a condition that developed during an outpatient encounter.

 

The POA indicator is in the shaded area. Reporting codes are:

Code:                     Definition:

Y                            Yes

N                            No

U                            No information in the record

W                           Clinically undetermined

1 or blank  - Exempt from POA reporting

*Blank or 1 is only allowed for diagnoses excluded by CMS for the specific diagnosis code.

 

 

 

 

67 A through Q

Other Diagnosis Codes

Required if applicable

Other Diagnosis Codes Enter the diagnosis codes corresponding to all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. 

DO NOT USE DECIMALS.

 

68

Special Note

Note:  Facilities may place the adjustment or void error reason code in this locator.  If nothing here, DMAS will default to error codes:  1052 – miscellaneous void or 1053 – miscellaneous adjustment.

 

 

 

69

Admitting Diagnosis

Required

Admitting Diagnosis – Enter the diagnosis code describing the patient’s diagnosis at the time of admission.  DO NOT USE DECIMALS.

 

 

 

70 a-c

Patient’s Reason for Visit

Required if applicable

 

Patient’s Reason for Visit – Enter the diagnosis code describing the patient’s reason for visit at the time of inpatient or unscheduled outpatient registration.

DO NOT USE DECIMALS.

 

 

 

71

Prospective Payment System (PPS) Code

Prospective Payment SystemEnter the PPS code assigned to the claim to identify the DRG based on the grouper software called for under contract with the primary payer.

 

 

 

72

External Cause of Injury

Required if applicable

External Cause of Injury - Enter the diagnosis code pertaining to external causes of injuries, poisoning, or adverse effect. 

DO NOT USE DECIMALS.

Present on Admission (POA) Indicator – The locator for the POA is directly after the ICD- diagnosis code in the red shaded field and is required for the External Cause of Injury code.  The POA indicator is a required field and is  to be indicated if:

  • the diagnosis was known at the time of admission, or
  • the diagnosis was clearly present, but not diagnosed, until after admission took place or
  • was a condition that developed during an outpatient encounter.

 

The POA indicator is in the shaded area. Reporting codes are:

Code:                     Definition:

Y                            Yes

N                            No

U                            No information in the record

W                           Clinically undetermined

1 or blank              Exempt from POA reporting

 

*Blank or 1 is only allowed for diagnoses excluded by CMS for the specific diagnosis code.

 

 

 

 

73

Reserved

Reserved for Assignment by the NUBC

 

 

 

74

Principal Procedure Code and Date

Required if applicable

Principal Procedure Code and Date – Enter the ICD- procedure code that identifies the inpatient principal procedure performed at the claim level during the period covered by this bill and the corresponding date.

 

 

 

Note: For inpatient claims, a procedure code or one of the diagnosis codes of Z5309 through Z538 must appear in this locator (or locator 67) when revenue codes 0360-0369 are used in locator 42 or the claim will be rejected.

 

Procedures that are done in the Emergency Room (ER) one day prior to the member being admitted for an inpatient hospitalization from the ER must be included on the inpatient claim.

DO NOT USE DECIMALS.

 

74a-e

Other Procedure Codes and Date

Required if applicable

Other Procedure Codes and Date – Enter the ICD- procedure codes identifying all significant procedures other than the principal procedure and the dates on which the procedures were performed. Report those that are most important for the episode of care and specifically any therapeutic procedures closely related to the principal diagnosis.   DO NOT USE DECIMALS.

 

 

 

75

Reserved

Reserved for assignment by the NUBC

 

 

 

76

Attending Provider Name and Identifiers

Required

Attending Provider Name and Identifiers - Enter the individual who has overall responsibility for the patient’s medical care and treatment reported in this claim.

 

Inpatient:  Enter the  Attending NPI  number.

 

Outpatient:  Enter the  NPI number for the physician who performs the principal procedure.

 

 

 

                                                                                                                                                 

77

Operating Physician Name and Identifiers

Required if applicable

Operating Physician Name and Identifiers - Enter the name and the  NPI number of the individual with the primary responsibility for performing the surgical procedure(s).  This is required when there is a surgical procedure on the claim.

 

Inpatient:  Enter the  NPI number assigned by Medicaid for the operating physician attending the patient.

 

Outpatient:  Enter the  NPI number assigned by Medicaid for the operating physician who performs the principal procedure.

 

 

 

 

78 - 79

Other Provider Name and Identifiers

Required if applicable

Other Physician ID. - Enter the  NPI for the Primary Care Physician (PCP) who authorized the inpatient stay or outpatient visit. 

 

 

For Client Medical Management (CMM) patients referred to the emergency room by the PCP, enter the NPI number and attach the Practitioner Referral Form (DMAS-70).  Non-emergency Emergency Room visits will be paid at a reduced rate.  Enter the  NPI PCP provider number for all inpatient stays.

 

For Hospice Providers: If revenue code 0658 is billed, then enter the nursing facility provider NPI number in this locator. 

80

Remarks Field

Remarks Field – Enter additional information necessary to adjudicate the claim.  Enter a brief description of the reason for the submission of the adjustment or void.   If there is a delay in filing, indicate the reason for the delay here and/or include an attachment.   Provide other information necessary to adjudicate the claim.

 

 

 

81

Code-Code Field

Required if applicable

Code-Code Field – Enter the provider taxonomy code for the billing provider when the adjudication of the claim is known to be impacted.  DMAS will be using this field to capture taxonomy for claims that are submitted with one NPI for multiple business types or locations (eg, Rehabilitative or Psychiatric units within an acute care facility; Home Health Agency with multiple locations).

 

Code B3 is to be entered in first (small) space and the provider taxonomy code is to be entered in the (second) large space.  The third space should be blank.

 

Note:   Hospitals with one NPI must use one of the taxonomy codes below when submitting claims for  the different business types noted below:

 

Service Type Description

Taxonomy Code(s)

Hospital, General

282N00000X

Rehabilitation Unit of Hospital

223Y00000X

Psychiatric Unit of Hospital

273R00000X

Private Mental Hospital (inpatient)

283Q00000X

Rehabilitation Hospital

283X00000X

Psychiatric Residential Inpatient Facility

323P00000X- Psychiatric Residential Treatment Facility

 

Transportation-Emergency Air or Ground Ambulance

3416A0800X – Air Transport

3416L0300X – Land Emergency Transport

Clinical Medical Laboratory

291U00000X

Independent Physiological Lab

293D00000X

If you have a question related to Taxonomy, please e-mail DMAS at NPI@dmas.virginia.gov.

Mailing Address for Claims

Forward the original with any attachments for consideration of payment to:

Department of Medical Assistance Services

P.O. Box 27443

Richmond, Virginia  23261-7443

Providers are encouraged to maintain a copy of the claim in their provider files for future reference.

Billing Instructions: UB-04 (CMS-1450) Adjustment and Void Invoices (Hospital)

      To adjust a previously paid claim, complete the UB-04 CMS-1450 to reflect the proper conditions, services, and charges.

      Type of Bill (Locator 4) – Enter code 0117 for inpatient hospital services or enter code 0137 for outpatient services.

      Locator 64 – Document Control Number - Enter the sixteen digit claim  internal control number (ICN) of the paid claim to be adjusted.  The  ICN appears on the remittance voucher.

  • Locator 68 – Enter the four digit adjustment reason code (refer to the below listing for codes acceptable by DMAS.
  • Remarks (Locator 80) – Enter an explanation for the adjustment.

NOTE: Inpatient claims cannot be adjusted if the following information is being changed.  In order to correct these areas, the claim will need to be voided and resubmitted as an original claim.

  • Admission Date
  • From or Through Date
  • Discharge Status
  • Diagnosis Code(s)
  • Procedure Code(s)

Acceptable Adjustment Codes:

Code                    Description

1023

Primary Carrier has made additional payment

1024

Primary Carrier has denied payment

1025

Accommodation charge correction

1026

Patient payment amount changed

1027

Correcting service periods

1028

Correcting procedure/ service code

1029

Correcting diagnosis code

1030

Correcting charge

1031

Correcting units/visits/studies/procedures

1032

IC reconsideration of allowance, documented

1033

Correcting admitting, referring, prescribing, provider identification number

1053

Adjustment reason is in the Misc. Category

  • To void a previously paid claim, complete the following data elements on the UB-04 CMS-1450:
  • Type of Bill (Locator 4) – Enter code 0118 for inpatient hospital services or enter code 0138 for outpatient hospital services.
  • Locator 64 – Document Control Number - Enter the sixteen digit claim reference number of the paid claim to be voided.  The claim reference number appears on the remittance voucher.
  • Locator 68 – Enter the four digit void reason code (refer to the below listing for codes acceptable by DMAS.
  • Remarks (Locator 80) – Enter an explanation for the void.

Acceptable Void Codes:

Code

Description

1042

Original claim has multiple incorrect items

1044

Wrong provider identification number

1045

Wrong enrollee eligibility number

1046

Primary carrier has paid DMAS maximum allowance

1047

Duplicate payment was made

1048

Primary carrier has paid full charge

1051

Enrollee not my patient

1052

Miscellaneous

1060

Other insurance is available

Group Practice Billing Functionality (Hospital)

Providers defined in this manual are not eligible to submit claims as a Group Practice with the Virginia Medicaid Program.  Group Practice claim submissions are reserved for independently enrolled fee-for-service healthcare practitioners (physicians, podiatrists, psychologists, etc.) that share the same Federal Employer Identification Number.  Facility-based organizations (NPI Type 2) and providers assigned an Atypical Provider Identifier (API) may not utilize group billing functionality. 

Medicare Crossover:  If Medicare requires you to submit claims identifying an individual Rendering Provider, DMAS will use the Billing Provider NPI to adjudicate the Medicare Crossover Claim.  You will not enroll your organization as a Group Practice with Virginia Medicaid.

For more information on Group Practice enrollment and claim submissions using the CMS-1500 (02-12), please refer to the appropriate practitioner Provider Manual found at www.dmas.virginia.gov.

Instructions for Billing Medicare Crossover Part B Services (Hospital)

The Virginia Medical Assistance Program implemented the consolidation process for Virginia Medicare crossover process, referred to as the Coordination of Benefits Agreement (COBA) in January 23, 2006. This process resulted in the transferring the claims crossover functions from individual Medicare contractors to one national claims crossover contractor.

The COBA process is only using the 837 electronic claims format. Refer to the applicable 837 Implementation Guide and the Virginia Medicaid 837 Companion Guide at https://vamedicaid.dmas.virginia.gov/edi  for more information.

Beginning March 1, 2006, Virginia Medicaid began accepting secondary claims to Medicaid when Medicare is primary from providers and not just thru the COBA process. If you receive notification that your Medicare claims did not cross to Virginia Medicaid or the crossover claim has not shown on your Medicaid remittance advice after 30 days, you should submit your claim directly to Medicaid. These claims can be resubmitted directly to DMAS either electronically, via Direct Data Entry or by using the CMS 1500 (02-12) paper claim form. Refer to the applicable 837 Implementation Guide and the Virginia Medicaid 837 Companion Guide at https://vamedicaid.dmas.virginia.gov/edi for more information.

An electronic claim can be sent to Virginia Medicaid if you need to resubmit a crossover claim that originally denied, such as for other coverage, or if you need to adjust or void a paid crossover claim, such as to include patient liability.

NOTE: Medicaid eligibility is reaffirmed each month for most members. Therefore, bills must be for services provided during each calendar month, e.g., 01/01/06 – 01/31/06.

Billing Instructions: Instructions for Completing the Paper CMS-1500 (02-12) Form for Medicare and Medicare Advantage Plan Deductible, Coinsurance and Copay Payments for Professional Services (Effective 11/02/2014) (Hospital)

The Direct Data Entry (DDE) Crossover Part B claim form can be located through the MES Provider Portal. Please note that providers are encouraged to use DDE for submission of claims that cannot be submitted electronically to DMAS. Registration with MES is required to access and use DDE within the MES Provider Portal.

Once logged on to MES, choose Provider Resources and then select Claims. Providers have the ability to create a new initial claim, as well as a claim adjustment or a void through the DDE process. The status of the claim(s) submitted can be checked the next business day if claims were submitted by 5pm. DDE is provided at no cost to providers. Paper claim submissions should only be submitted when requested specifically by DMAS.

Purpose: A method of billing Medicare’s deductible, coinsurance and copay for professional Providers typically use Direct Data Entry (DDE), however, the CMS-1500 (02-12) form must be used in those instances where DMAS has requested the use of the paper form. The following instructions have numbered items corresponding to fields on the CMS-1500 (02-12).

NOTE:             Note changes in locator 11c and 24A lines 1-6 red shaded area. These changes are specific to Medicare Part B billing only.

Locator                                  Instructions                                                                    

1

REQUIRED

Enter an "X" in the MEDICAID box for the Medicaid Program.  Enter an “X” in the OTHER box for Temporary Detention Order (TDO) or Emergency Custody Order (ECO).

 

1a

REQUIRED

Insured's I.D. Number - Enter the 12-digit Virginia Medicaid Identification number for the member receiving the service.

 

2

REQUIRED

Patient's Name - Enter the name of the member receiving the service.

 

3

NOT REQUIRED

Patient's Birth Date

4

NOT REQUIRED

Insured's Name

5

NOT REQUIRED

Patient's Address

6

NOT REQUIRED

Patient Relationship to Insured

7

NOT REQUIRED

Insured's Address

8

NOT REQUIRED

Reserved for NUCC Use

9

NOT REQUIRED

Other Insured's Name

9a

NOT REQUIRED

Other Insured's Policy or Group Number

9b

NOT REQUIRED

Reserved for NUCC Use

9c

NOT REQUIRED

Reserved for NUCC Use

9d

NOT REQUIRED

Insurance Plan Name or Program Name

 

10

REQUIRED

Is Patient's Condition Related To: - Enter an "X" in the appropriate box. 

a. Employment?

b. Auto accident

c. Other Accident? (This includes schools, stores, assaults, etc.)  NOTE: The state should be entered if known.

 

10d

Conditional

Claim Codes (Designated by NUCC)

Medicare/Medicare Advantage Plan EOB should be attached.

11

NOT REQUIRED

Insured's Policy Number or FECA Number

11a

NOT REQUIRED

Insured's Date of Birth

11b

NOT REQUIRED

Other Claim ID

 

11c

REQUIRED

 

Insurance Plan or Program Name

Enter the word ‘CROSSOVER

IMPORTANT:  DO NOT enter ‘HMO COPAY’ when billing for Medicare/Medicare Advantage Plan copays! Only enter the word ‘CROSSOVER

 

11d

REQUIRED

If applicable

Is There Another Health Benefit Plan?

If Medicare/Medicare Advantage Plan and Medicaid only, check “NO”. Only check “Yes”, if there is additional insurance coverage other than Medicare/Medicare Advantage Plan and Medicaid.

12

NOT REQUIRED

Patient's or Authorized Person's Signature

13

NOT REQUIRED

Insured's or Authorized Person's Signature

14

NOT REQUIRED

 

Date of Current Illness, Injury, or Pregnancy

Enter date MM DD YY format

Enter Qualifier 431 – Onset of Current Symptoms or Illness

15

NOT REQUIRED

Other Date

16

NOT REQUIRED

Dates Patient Unable to Work in Current Occupation

17

NOT REQUIRED

 

Name of Referring Physician or Other Source – Enter the name of the referring physician.

17a shaded red

NOT REQUIRED

 

I.D. Number of Referring Physician - The qualifier ‘ZZ’ is be entered if the provider taxonomy code is needed to adjudicate the claim.

Refer to the specific Medicaid Provider manual for special Billing Instructions for specific services.

17b

NOT REQUIRED

 

I.D. Number of Referring Physician - Enter the National Provider Identifier of the referring physician. 

18

NOT REQUIRED

Hospitalization Dates Related to Current Services

19

NOT REQUIRED

 

Additional Claim Information

Enter the CLIA #.

20

NOT REQUIRED

Outside Lab?

 

21

A-L

REQUIRED

Diagnosis or Nature of Illness or Injury - Enter the appropriate ICD diagnosis code, which describes the nature of the illness or injury for which the service was rendered in locator 24E.  Note: Line ‘A’ field should be the Primary/Admitting diagnosis followed by the next highest level of specificity in lines B-L.

Note:  ICD Ind. Not required at this time. 

 

22

REQUIRED

If applicable

 

Resubmission Code – Original Reference Number.  Required for adjustment or void. 

Enter one of the following resubmission codes for an adjustment:

 

1023     Primary Carrier has made additional payment

1024     Primary Carrier has denied payment

1026     Patient payment amount changed

1027     Correcting service periods

1028     Correcting procedure/service code

1029     Correcting diagnosis code

1030     Correcting charges

1031     Correcting units/visits/studies/procedures

1032     IC reconsideration of allowance, documented

1033  Correcting admitting, referring, prescribing provider identification number

1053     Adjustment reason is in the miscellaneous category

 

Enter one of the following resubmission codes for a void:

 

1042     Original claim has multiple incorrect items

1044     Wrong provider identification number

1045     Wrong member eligibility number

1046   Primary carrier has paid DMAS’ maximum allowance

1047     Duplicate payment was made

1048     Primary carrier has paid full charge

1051     Member is not my patient

1052     Void reason is in the miscellaneous category

1060     Other insurance is available

 

Original Reference Number - Enter the claim reference number/ICN of the Virginia Medicaid paid claim. This number may be obtained from the remittance voucher and is required to identify the claim to be adjusted or voided. Only one paid claim can be adjusted or voided on each CMS-1500 (02-12) claim form. (Each line under Locator 24 is one claim).

 

 

NOTE: ICNs can only be adjusted or voided through the MES up to three years from the date the claim was paid. After three years, ICNs are purged from the MES and can no longer be adjusted or voided through the system. If an ICN is purged from the system, the provider must send a refund check made payable to DMAS and include the following information:

            A cover letter on the provider’s letterhead which includes the current address, contact name and phone number.

            An explanation about the refund.

            A copy of the remittance page(s) as it relates to the refund check amount.

Mail all information to:

Department of Medical Assistance Services

              Attn:  Fiscal & Procurement

              Division, Cashier

               600 East Broad St. Suite 1300

               Richmond, VA 23219

 

23

REQUIRED

If applicable

 

 

Service Authorization (SA) Number – Enter the PA number for approved services that require a service authorization.

 

NOTE: The locators 24A through 24J have been divided into open and shaded line areas.  The shaded area is ONLY for supplemental information.  DMAS has given instructions for the supplemental information that is required when needed for DMAS claims processing. ENTER REQUIRED INFORMATION ONLY.

 

24A

lines

1-6

open area

 

REQUIRED

Dates of Service - Enter the from and through dates in a 2-digit format for the month, day and year (e.g., 01 01 14). 

 

 

24A-H

lines 1-6

red shaded

REQUIRED

 

 

DMAS is requiring the use of the following qualifiers in the red shaded for Part B billing:

A1 =    Deductible  (Example: A120.00) = $20.00 ded 

A2 =   Coinsurance (Example: A240.00) = $40.00 coins

A7=    Copay (Example: A735.00) = $35.00 copay

AB=   Allowed by Medicare/Medicare Advantage Plan (Example AB145.10) = $145.10 Allowed Amount  

MA= Amount Paid by Medicare/Medicare Advantage   Plan  (Example MA27.08) see details below

CM= Other insurance payment (not Medicare/Medicare Advantage Plan) if applicable (Example CM27.08) see details below

N4 =   National Drug Code (NDC)+Unit of Measurement

 

‘MA’:  This qualifier is to be used to show Medicare/Medicare Advantage Plan’s payment.  The ‘MA’ qualifier is to be followed by the dollar/cents amount of the payment by Medicare/Medicare Advantage Plan

Example:

 Payment by Medicare/Medicare Advantage Plan is $27.08; enter MA27.08 in the red shaded area

 

‘CM’:  This qualifier is to be used to show the amount paid by the insurance carrier other than Medicare/Medicare Advantage plan.  The ‘CM’ qualifier is to be followed by the dollar/cents amount of the payment by the other insurance.

Example:

 Payment by the other insurance plan is $27.08; enter CM27.08 in the red shaded area

 

NOTE: No spaces are allowed between the qualifier and dollars.  No $ symbol is allowed. The decimal between dollars and cents is required.

 

DMAS is requiring the use of the qualifier ‘N4’.  This qualifier is to be used for the National Drug Code (NDC) whenever a drug related HCPCS code is submitted in 24D to DMAS.  The Unit of Measurement Qualifiers must follow the NDC number.  The unit of measurement qualifier code is followed by the metric decimal quantity or unit. Do not enter a space between the unit of measurement qualifier and NDC.

Example: N400026064871UN1.0 

Any spaces unused for the quantity should be left blank.

Unit of Measurement Qualifier Codes:

F2 – International Units

GR – Gram

ML – Milliliter

UN – Unit

 

 

Examples of NDC quantities for various dosage forms as follows:

a. Tablets/Capsules – bill per UN

b. Oral Liquids – bill per ML

c. Reconstituted (or liquids) injections – bill per ML

d. Non-reconstituted injections (I.E. vial of Rocephin

powder) – bill as UN (1 vial = 1 unit)

e. Creams, ointments, topical powders – bill per GR

f. Inhalers – bill per GR

 

Note: All supplemental information entered in locator 24A through 24H is to be left justified.

 

 

Examples:

  1. Deductible is $10.00, Medicare/Medicare Advantage Plan Allowed Amt is $20.00, Medicare/Medicare Advantage Plan Paid Amt is $16.00, Coinsurance is $4.00.
  • Enter:A110.00 AB20.00 MA16.00 A24.00

 

  1. Copay is $35.00, Medicare/Medicare Advantage Plan Paid Amt is $0.00

Medicare/Medicare Advantage Plan Allowed Amt is $100.00

  • Enter: A735.00 MA0.00 AB100.00

 

  1. Medicare/Medicare Advantage Plan Paid Amt is $10.00, Other Insurance payment is $10.00, Medicare/Medicare Advantage Plan Allowed Amt is $10.00, Coinsurance is $5.00, NDC is 12345678911, Unit of measure is 2 grams
  • Enter:

MA10.00 CM10.00 AB10.00 A25.00 N412345678911GR2

 

**Allow a space in between each qualifier set**

 

 

 

24B

open area

REQUIRED

Place of Service - Enter the 2-digit CMS code, which describes where the services were rendered. 

 

 

24C

open area

REQUIRED

If applicable

Emergency Indicator - Enter either ‘Y’ for YES or leave blank.  DMAS will not accept any other indicators for this locator.

 

24D

open  area

 

 

REQUIRED

Procedures, Services or Supplies – CPT/HCPCS –

ter HCPCS Code, which des Enter the CPT/HCPCS code that describes the procedure rendered or the service provided.

                                                  Modifier - Enter the appropriate CPT/HCPCS modifiers if applicable. 

 

 

 

24E

open area

REQUIRED

Diagnosis Code - Enter the diagnosis code reference letter A-L (pointer) as shown in Locator 21 to relate the date of service and the procedure performed to the primary diagnosis.  The primary diagnosis code reference letter for each service should be listed first.  NOTE:  A maximum of 4 diagnosis code reference letter pointers should be entered.  Claims with values other than A-L in Locator 24-E or blank will be denied. 

 

24F

open area

REQUIRED

Charges - Enter the Medicare/Medicare Advantage Plan billed amount for the procedure/services. NOTE: Enter the Medicare/Medicare Advantage Plan Copay amount as the charged amount when billing for the Medicare/Medicare Advantage Plan Copay ONLY.

.

 

 

24G

open area

REQUIRED

Days or Unit - Enter the number of times the procedure, service, or item was provided during the service period.

 

24H

open area

REQUIRED

If applicable

EPSDT or Family Planning - Enter the appropriate indicator.  Required only for EPSDT or family planning services.

1 - Early and Periodic, Screening, Diagnosis and Treatment Program Services

2 - Family Planning Service

 

 

 

 

24I

open

REQUIRED

If applicable

NPI – This is to identify that it is a NPI that is in locator 24J

 

 

24 I

red-shaded

REQUIRED

If applicable

 

 

24J

open

REQUIRED

If applicable

Rendering provider ID# - Enter the 10 digit NPI number for the provider that performed/rendered the care.

 

24J

red-shaded

REQUIRED

If applicable

Rendering provider ID# - If the qualifier ‘ZZ’ was entered in 24I shaded area enter the provider taxonomy code if the NPI is entered in locator 24J open line.

 

25

NOT REQUIRED

Federal Tax I.D. Number

 

26

REQUIRED

Patient's Account Number – Up to FOURTEEN alpha-numeric characters are acceptable.

 

27

NOT REQUIRED

Accept Assignment

 

28

REQUIRED

Total Charge - Enter the total charges for the services in 24F lines 1-6 

 

 

29

REQUIRED

If applicable

Amount Paid – For personal care and waiver services only – enter the patient pay amount that is due from the patient.  NOTE: The patient pay amount is taken from services billed on 24A - line 1.  If multiple services are provided on same date of service, then another form must be completed since only one line can be submitted if patient pay is to be considered in the processing of this service.

 

30

NOT REQUIRED

Rsvd for NUCC Use

 

31

REQUIRED

Signature of Physician or Supplier Including Degrees or Credentials - The provider or agent must sign and date the invoice in this block.

 

32

REQUIRED

If applicable

Service Facility Location Information – Enter the name as first line, address as second line, city, state and 9 digit zip code as third line for the location where the services were rendered.  NOTE: For physician with multiple office locations, the specific Zip code must reflect the office location where services given.  Do NOT use commas, periods or other punctuations in the address.  Enter space between city and state.  Include the hyphen for the 9 digit zip code.

 

32a open

REQUIRED

If applicable

 

NPI # - Enter the 10 digit NPI number of the service location.

 

32b

red shaded

REQUIRED

If applicable

Other ID#: - The qualifier ‘1D’ is required with the API entered in this locator. The qualifier of ‘ZZ’ is required with the provider taxonomy code if the NPI is entered in locator 32a open line.

 

33

REQUIRED

Billing Provider Info and PH # - Enter the billing name as first line, address as second line, city, state and 9-digit zip code as third line.  This locator is to identify the provider that is requesting to be paid.

NOTE: Do NOT use commas, periods or other punctuations in the address.  Enter space between city and state.  Include the hyphen for the 9 digit zip code.  The phone number is to be entered in the area to the right of the field title. Do not use hyphen or space as separator within the telephone number.

 

33a open

REQUIRED

NPI – Enter the 10 digit NPI number of the billing provider.

 

 

33b

red shaded

REQUIRED

If applicable

Other Billing ID - The qualifier ‘1D’ is required with the API entered in this locator. The qualifier ‘ZZ’ is required with the provider taxonomy code if the NPI is entered in locator 33a open line.

NOTE: DO NOT use commas, periods, space, hyphens or other punctuations between the qualifier and the number.

The information may be typed (recommend font Sans Serif 12) or legibly handwritten.  Retain a copy for the office files.

Mail the completed claims to:

Department of Medical Assistance Services

CMS Crossover

P. O. Box 27444

Richmond, Virginia 23261-7444

Billing Instructions: Invoice Processing (Hospital)

The Medicaid invoice processing system utilizes a sophisticated electronic system to process Medicaid claims.  Once a claim has been received, imaged, assigned a cross-reference number, and entered into the system, it is placed in one of the following categories:

      Remittance Voucher

  • Approved - Payment is approved or pended.
  • Denied - Payment cannot be approved because of the reason stated on the remittance voucher.
  • Pend - Payment is pended for claim to be manually reviewed by DMAS staff or waiting on further information from provider.

     No Response - If one of the above responses has not been received within 30 days, the provider should assume non-delivery and rebill  using a new invoice form. The provider's failure to follow up on these situations does not warrant individual or additional consideration for late billing.

Please use this link to search for DMAS Forms:

https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderFormsSearch

 

Billing Instructions: Exhibits/Forms (Hospital)

Newborn Eligibility Notification:

DMAS-213

UB-04 CMS-1450:

UB-04

Claim Attachment Form (DMAS-3 R 06/03) and Instructions:

DMAS-3

Revenue Code Searchable List:

Revenue Codes

Billing Instructions: Lane Reduction ER Code List (Hospital)

ICD-10 Codes

ICD-10 Description

A09.

Infectious gastroenteritis and colitis, unspecified

J02.0

Streptococcal pharyngitis

J03.00

Acute streptococcal tonsillitis, unspecified

J03.01

Acute recurrent streptococcal tonsillitis

B01.9

Varicella without complication

B02.9

Zoster without complications

B00.2

Herpesviral gingivostomatitis and pharyngotonsillitis

B00.9

Herpesviral infection, unspecified

B09.

Unspecified viral infection characterized by skin and mucous membrane lesions

B08.5

Enteroviral vesicular pharyngitis

B08.4

Enteroviral vesicular stomatitis with exanthem

B27.80

Other infectious mononucleosis without complication

B27.81

Other infectious mononucleosis with polyneuropathy

B27.89

Other infectious mononucleosis with other complication

B27.90

Infectious mononucleosis, unspecified without complication

B27.91

Infectious mononucleosis, unspecified with polyneuropathy

B27.99

Infectious mononucleosis, unspecified with other complication

B07.9

Viral wart, unspecified

B07.0

Plantar wart

B97.11

Coxsackievirus as the cause of diseases classified elsewhere

B97.10

Unspecified enterovirus as the cause of diseases classified elsewhere

B97.89

Other viral agents as the cause of diseases classified elsewhere

A54.00

Gonococcal infection of lower genitourinary tract, unspecified

A54.02

Gonococcal vulvovaginitis, unspecified

A54.09

Other gonococcal infection of lower genitourinary tract

A54.1

Gonococcal infection of lower genitourinary tract with periurethral and accessory gland abscess

A64.

Unspecified sexually transmitted disease

B35.0

Tinea barbae and tinea capitis

B35.4

Tinea corporis

B35.5

Tinea imbricata

B37.0

Candidal stomatitis

B37.83

Candidal cheilitis

B37.3

Candidiasis of vulva and vagina

B37.9

Candidiasis, unspecified

A59.01

Trichomonal vulvovaginitis

B86.

Scabies

E11.9

Type 2 diabetes mellitus without complications

E13.9

Other specified diabetes mellitus without complications

E10.9

Type 1 diabetes mellitus without complications

E11.65

Type 2 diabetes mellitus with hyperglycemia

E10.65

Type 1 diabetes mellitus with hyperglycemia

E11.69

Type 2 diabetes mellitus with other specified complication

E13.10

Other specified diabetes mellitus with ketoacidosis without coma

E10.10

Type 1 diabetes mellitus with ketoacidosis without coma

E10.69

Type 1 diabetes mellitus with other specified complication

E11.620

Type 2 diabetes mellitus with diabetic dermatitis

E11.621

Type 2 diabetes mellitus with foot ulcer

E11.622

Type 2 diabetes mellitus with other skin ulcer

E11.628

Type 2 diabetes mellitus with other skin complications

E11.638

Type 2 diabetes mellitus with other oral complications

E11.649

Type 2 diabetes mellitus with hypoglycemia without coma

E13.620

Other specified diabetes mellitus with diabetic dermatitis

E13.621

Other specified diabetes mellitus with foot ulcer

E13.622

Other specified diabetes mellitus with other skin ulcer

E13.628

Other specified diabetes mellitus with other skin complications

E13.638

Other specified diabetes mellitus with other oral complications

E13.649

Other specified diabetes mellitus with hypoglycemia without coma

E13.65

Other specified diabetes mellitus with hyperglycemia

E13.69

Other specified diabetes mellitus with other specified complication

E10.620

Type 1 diabetes mellitus with diabetic dermatitis

E10.621

Type 1 diabetes mellitus with foot ulcer

E10.622

Type 1 diabetes mellitus with other skin ulcer

E10.628

Type 1 diabetes mellitus with other skin complications

E10.638

Type 1 diabetes mellitus with other oral complications

E10.649

Type 1 diabetes mellitus with hypoglycemia without coma

E11.8

Type 2 diabetes mellitus with unspecified complications

E13.8

Other specified diabetes mellitus with unspecified complications

E16.2

Hypoglycemia, unspecified

M10.9

Gout, unspecified

G44.209

Tension-type headache, unspecified, not intractable

G43.909

Migraine, unspecified, not intractable, without status migrainosus

G51.0

Bell's palsy

G56.00

Carpal tunnel syndrome, unspecified upper limb

G56.01

Carpal tunnel syndrome, right upper limb

G56.02

Carpal tunnel syndrome, left upper limb

G56.90

Unspecified mononeuropathy of unspecified upper limb

G56.91

Unspecified mononeuropathy of right upper limb

G56.92

Unspecified mononeuropathy of left upper limb

H10.30

Unspecified acute conjunctivitis, unspecified eye

H10.31

Unspecified acute conjunctivitis, right eye

H10.32

Unspecified acute conjunctivitis, left eye

H10.33

Unspecified acute conjunctivitis, bilateral

H10.021

Other mucopurulent conjunctivitis, right eye

H10.022

Other mucopurulent conjunctivitis, left eye

H10.023

Other mucopurulent conjunctivitis, bilateral

H10.029

Other mucopurulent conjunctivitis, unspecified eye

H10.411

Chronic giant papillary conjunctivitis, right eye

H10.412

Chronic giant papillary conjunctivitis, left eye

H10.413

Chronic giant papillary conjunctivitis, bilateral

H10.419

Chronic giant papillary conjunctivitis, unspecified eye

H10.45

Other chronic allergic conjunctivitis

H10.9

Unspecified conjunctivitis

H11.001

Unspecified pterygium of right eye

H11.002

Unspecified pterygium of left eye

H11.003

Unspecified pterygium of eye, bilateral

H11.009

Unspecified pterygium of unspecified eye

H11.011

Amyloid pterygium of right eye

H11.012

Amyloid pterygium of left eye

H11.013

Amyloid pterygium of eye, bilateral

H11.019

Amyloid pterygium of unspecified eye

H00.011

Hordeolum externum right upper eyelid

H00.012

Hordeolum externum right lower eyelid

H00.013

Hordeolum externum right eye, unspecified eyelid

H00.014

Hordeolum externum left upper eyelid

H00.015

Hordeolum externum left lower eyelid

H00.016

Hordeolum externum left eye, unspecified eyelid

H00.019

Hordeolum externum unspecified eye, unspecified eyelid

H00.031

Abscess of right upper eyelid

H00.032

Abscess of right lower eyelid

H00.033

Abscess of eyelid right eye, unspecified eyelid

H00.034

Abscess of left upper eyelid

H00.035

Abscess of left lower eyelid

H00.036

Abscess of eyelid left eye, unspecified eyelid

H00.039

Abscess of eyelid unspecified eye, unspecified eyelid

H00.11

Chalazion right upper eyelid

H00.12

Chalazion right lower eyelid

H00.13

Chalazion right eye, unspecified eyelid

H00.14

Chalazion left upper eyelid

H00.15

Chalazion left lower eyelid

H00.16

Chalazion left eye, unspecified eyelid

H00.19

Chalazion unspecified eye, unspecified eyelid

H57.10

Ocular pain, unspecified eye

H57.11

Ocular pain, right eye

H57.12

Ocular pain, left eye

H57.13

Ocular pain, bilateral

H60.00

Abscess of external ear, unspecified ear

H60.01

Abscess of right external ear

H60.02

Abscess of left external ear

H60.03

Abscess of external ear, bilateral

H60.10

Cellulitis of external ear, unspecified ear

H60.11

Cellulitis of right external ear

H60.12

Cellulitis of left external ear

H60.13

Cellulitis of external ear, bilateral

H60.311

Diffuse otitis externa, right ear

H60.312

Diffuse otitis externa, left ear

H60.313

Diffuse otitis externa, bilateral

H60.319

Diffuse otitis externa, unspecified ear

H60.321

Hemorrhagic otitis externa, right ear

H60.322

Hemorrhagic otitis externa, left ear

H60.323

Hemorrhagic otitis externa, bilateral

H60.329

Hemorrhagic otitis externa, unspecified ear

H60.391

Other infective otitis externa, right ear

H60.392

Other infective otitis externa, left ear

H60.393

Other infective otitis externa, bilateral

H60.399

Other infective otitis externa, unspecified ear

H61.20

Impacted cerumen, unspecified ear

H61.21

Impacted cerumen, right ear

H61.22

Impacted cerumen, left ear

H61.23

Impacted cerumen, bilateral

H65.191

Other acute nonsuppurative otitis media, right ear

H65.192

Other acute nonsuppurative otitis media, left ear

H65.193

Other acute nonsuppurative otitis media, bilateral

H65.194

Other acute nonsuppurative otitis media, recurrent, right ear

H65.195

Other acute nonsuppurative otitis media, recurrent, left ear

H65.196

Other acute nonsuppurative otitis media, recurrent, bilateral

H65.197

Other acute nonsuppurative otitis media recurrent, unspecified ear

H65.199

Other acute nonsuppurative otitis media, unspecified ear

H65.00

Acute serous otitis media, unspecified ear

H65.01

Acute serous otitis media, right ear

H65.02

Acute serous otitis media, left ear

H65.03

Acute serous otitis media, bilateral

H65.04

Acute serous otitis media, recurrent, right ear

H65.05

Acute serous otitis media, recurrent, left ear

H65.06

Acute serous otitis media, recurrent, bilateral

H65.07

Acute serous otitis media, recurrent, unspecified ear

H65.20

Chronic serous otitis media, unspecified ear

H65.21

Chronic serous otitis media, right ear

H65.22

Chronic serous otitis media, left ear

H65.23

Chronic serous otitis media, bilateral

H65.90

Unspecified nonsuppurative otitis media, unspecified ear

H65.91

Unspecified nonsuppurative otitis media, right ear

H65.92

Unspecified nonsuppurative otitis media, left ear

H65.93

Unspecified nonsuppurative otitis media, bilateral

H66.001

Acute suppurative otitis media without spontaneous rupture of ear drum, right ear

H66.002

Acute suppurative otitis media without spontaneous rupture of ear drum, left ear

H66.003

Acute suppurative otitis media without spontaneous rupture of ear drum, bilateral

H66.004

Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, right ear

H66.005

Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, left ear

H66.006

Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, bilateral

H66.007

Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, unspecified ear

H66.009

Acute suppurative otitis media without spontaneous rupture of ear drum, unspecified ear

H66.90

Otitis media, unspecified, unspecified ear

H66.91

Otitis media, unspecified, right ear

H66.92

Otitis media, unspecified, left ear

H66.93

Otitis media, unspecified, bilateral

H72.90

Unspecified perforation of tympanic membrane, unspecified ear

H72.91

Unspecified perforation of tympanic membrane, right ear

H72.92

Unspecified perforation of tympanic membrane, left ear

H72.93

Unspecified perforation of tympanic membrane, bilateral

H83.3X1

Noise effects on right inner ear

H83.3X2

Noise effects on left inner ear

H83.3X3

Noise effects on inner ear, bilateral

H83.3X9

Noise effects on inner ear, unspecified ear

H93.11

Tinnitus, right ear

H93.12

Tinnitus, left ear

H93.13

Tinnitus, bilateral

H93.19

Tinnitus, unspecified ear

H92.10

Otorrhea, unspecified ear

H92.11

Otorrhea, right ear

H92.12

Otorrhea, left ear

H92.13

Otorrhea, bilateral

H92.20

Otorrhagia, unspecified ear

H92.21

Otorrhagia, right ear

H92.22

Otorrhagia, left ear

H92.23

Otorrhagia, bilateral

H92.01

Otalgia, right ear

H92.02

Otalgia, left ear

H92.03

Otalgia, bilateral

H92.09

Otalgia, unspecified ear

H93.8X1

Other specified disorders of right ear

H93.8X2

Other specified disorders of left ear

H93.8X3

Other specified disorders of ear, bilateral

H93.8X9

Other specified disorders of ear, unspecified ear

H94.80

Other specified disorders of ear in diseases classified elsewhere, unspecified ear

H94.81

Other specified disorders of right ear in diseases classified elsewhere

H94.82

Other specified disorders of left ear in diseases classified elsewhere

H94.83

Other specified disorders of ear in diseases classified elsewhere, bilateral

I10.

Essential (primary) hypertension

I50.9

Heart failure, unspecified

K64.9

Unspecified hemorrhoids

J00.

Acute nasopharyngitis [common cold]

J01.00

Acute maxillary sinusitis, unspecified

J01.01

Acute recurrent maxillary sinusitis

J01.90

Acute sinusitis, unspecified

J01.91

Acute recurrent sinusitis, unspecified

J02.8

Acute pharyngitis due to other specified organisms

J02.9

Acute pharyngitis, unspecified

J03.80

Acute tonsillitis due to other specified organisms

J03.81

Acute recurrent tonsillitis due to other specified organisms

J03.90

Acute tonsillitis, unspecified

J03.91

Acute recurrent tonsillitis, unspecified

J04.10

Acute tracheitis without obstruction

J06.9

Acute upper respiratory infection, unspecified

J20.8

Acute bronchitis due to other specified organisms

J20.9

Acute bronchitis, unspecified

J31.0

Chronic rhinitis

J32.0

Chronic maxillary sinusitis

J32.9

Chronic sinusitis, unspecified

J30.1

Allergic rhinitis due to pollen

J30.0

Vasomotor rhinitis

J30.9

Allergic rhinitis, unspecified

J18.1

Lobar pneumonia, unspecified organism

J18.0

Bronchopneumonia, unspecified organism

J18.8

Other pneumonia, unspecified organism

J18.9

Pneumonia, unspecified organism

J10.1

Influenza due to other identified influenza virus with other respiratory manifestations

J11.1

Influenza due to unidentified influenza virus with other respiratory manifestations

J40.

Bronchitis, not specified as acute or chronic

J44.9

Chronic obstructive pulmonary disease, unspecified

J44.1

Chronic obstructive pulmonary disease with (acute) exacerbation

J42.

Unspecified chronic bronchitis

J43.9

Emphysema, unspecified

J43.0

Unilateral pulmonary emphysema [MacLeod's syndrome]

J43.1

Panlobular emphysema

J43.2

Centrilobular emphysema

J43.8

Other emphysema

J45.20

Mild intermittent asthma, uncomplicated

J45.30

Mild persistent asthma, uncomplicated

J45.40

Moderate persistent asthma, uncomplicated

J45.50

Severe persistent asthma, uncomplicated

J45.22

Mild intermittent asthma with status asthmaticus

J45.32

Mild persistent asthma with status asthmaticus

J45.42

Moderate persistent asthma with status asthmaticus

J45.52

Severe persistent asthma with status asthmaticus

J45.21

Mild intermittent asthma with (acute) exacerbation

J45.31

Mild persistent asthma with (acute) exacerbation

J45.41

Moderate persistent asthma with (acute) exacerbation

J45.51

Severe persistent asthma with (acute) exacerbation

J45.990

Exercise induced bronchospasm

J45.991

Cough variant asthma

J45.909

Unspecified asthma, uncomplicated

J45.998

Other asthma

J45.902

Unspecified asthma with status asthmaticus

J45.901

Unspecified asthma with (acute) exacerbation

K04.4

Acute apical periodontitis of pulpal origin

K04.7

Periapical abscess without sinus

K08.8

Other specified disorders of teeth and supporting structures

M26.79

Other specified alveolar anomalies

K08.9

Disorder of teeth and supporting structures, unspecified

K12.2

Cellulitis and abscess of mouth

K12.0

Recurrent oral aphthae

K13.1

Cheek and lip biting

K13.4

Granuloma and granuloma-like lesions of oral mucosa

K13.6

Irritative hyperplasia of oral mucosa

K13.70

Unspecified lesions of oral mucosa

K13.79

Other lesions of oral mucosa

K21.9

Gastro-esophageal reflux disease without esophagitis

K40.90

Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent

K52.89

Other specified noninfective gastroenteritis and colitis

K52.9

Noninfective gastroenteritis and colitis, unspecified

K58.0

Irritable bowel syndrome with diarrhea

K58.9

Irritable bowel syndrome without diarrhea

K60.0

Acute anal fissure

K60.1

Chronic anal fissure

K60.2

Anal fissure, unspecified

N10.

Acute tubulo-interstitial nephritis

N11.9

Chronic tubulo-interstitial nephritis, unspecified

N12.

Tubulo-interstitial nephritis, not specified as acute or chronic

N13.6

Pyonephrosis

N30.00

Acute cystitis without hematuria

N30.01

Acute cystitis with hematuria

N30.90

Cystitis, unspecified without hematuria

N30.91

Cystitis, unspecified with hematuria

N34.1

Nonspecific urethritis

N34.2

Other urethritis

N39.0

Urinary tract infection, site not specified

N45.1

Epididymitis

N45.2

Orchitis

N45.3

Epididymo-orchitis

N47.6

Balanoposthitis

N48.1

Balanitis

N50.9

Disorder of male genital organs, unspecified

R10.2

Pelvic and perineal pain

N64.4

Mastodynia

N63.

Unspecified lump in breast

N73.5

Female pelvic peritonitis, unspecified

N73.9

Female pelvic inflammatory disease, unspecified

N72.

Inflammatory disease of cervix uteri

N76.0

Acute vaginitis

N76.1

Subacute and chronic vaginitis

N76.2

Acute vulvitis

N76.3

Subacute and chronic vulvitis

N83.20

Unspecified ovarian cysts

N83.29

Other ovarian cysts

N89.8

Other specified noninflammatory disorders of vagina

N94.4

Primary dysmenorrhea

N94.5

Secondary dysmenorrhea

N94.6

Dysmenorrhea, unspecified

N94.89

Other specified conditions associated with female genital organs and menstrual cycle

N92.0

Excessive and frequent menstruation with regular cycle

N92.5

Other specified irregular menstruation

N92.6

Irregular menstruation, unspecified

N89.7

Hematocolpos

N93.8

Other specified abnormal uterine and vaginal bleeding

N93.9

Abnormal uterine and vaginal bleeding, unspecified

O21.0

Mild hyperemesis gravidarum

O25.11

Malnutrition in pregnancy, first trimester

O25.12

Malnutrition in pregnancy, second trimester

O25.13

Malnutrition in pregnancy, third trimester

O99.281

Endocrine, nutritional and metabolic diseases complicating pregnancy, first trimester

O99.282

Endocrine, nutritional and metabolic diseases complicating pregnancy, second trimester

O99.283

Endocrine, nutritional and metabolic diseases complicating pregnancy, third trimester

O99.511

Diseases of the respiratory system complicating pregnancy, first trimester

O99.512

Diseases of the respiratory system complicating pregnancy, second trimester

O99.513

Diseases of the respiratory system complicating pregnancy, third trimester

O99.611

Diseases of the digestive system complicating pregnancy, first trimester

O99.612

Diseases of the digestive system complicating pregnancy, second trimester

O99.613

Diseases of the digestive system complicating pregnancy, third trimester

O99.711

Diseases of the skin and subcutaneous tissue complicating pregnancy, first trimester

O99.712

Diseases of the skin and subcutaneous tissue complicating pregnancy, second trimester

O99.713

Diseases of the skin and subcutaneous tissue complicating pregnancy, third trimester

O9A.111

Malignant neoplasm complicating pregnancy, first trimester

O9A.112

Malignant neoplasm complicating pregnancy, second trimester

O9A.113

Malignant neoplasm complicating pregnancy, third trimester

O9A.211

Injury, poisoning and certain other consequences of external causes complicating pregnancy, first trimester

O9A.212

Injury, poisoning and certain other consequences of external causes complicating pregnancy, second trimester

O9A.213

Injury, poisoning and certain other consequences of external causes complicating pregnancy, third trimester

L02.92

Furuncle, unspecified

L02.93

Carbuncle, unspecified

L02.511

Cutaneous abscess of right hand

L02.512

Cutaneous abscess of left hand

L02.519

Cutaneous abscess of unspecified hand

L03.011

Cellulitis of right finger

L03.012

Cellulitis of left finger

L03.019

Cellulitis of unspecified finger

L03.021

Acute lymphangitis of right finger

L03.022

Acute lymphangitis of left finger

L03.029

Acute lymphangitis of unspecified finger

L02.611

Cutaneous abscess of right foot

L02.612

Cutaneous abscess of left foot

L02.619

Cutaneous abscess of unspecified foot

L03.031

Cellulitis of right toe

L03.032

Cellulitis of left toe

L03.039

Cellulitis of unspecified toe

L03.041

Acute lymphangitis of right toe

L03.042

Acute lymphangitis of left toe

L03.049

Acute lymphangitis of unspecified toe

L02.01

Cutaneous abscess of face

L03.211

Cellulitis of face

L03.212

Acute lymphangitis of face

L02.211

Cutaneous abscess of abdominal wall

L02.212

Cutaneous abscess of back [any part, except buttock]

L02.213

Cutaneous abscess of chest wall

L02.214

Cutaneous abscess of groin

L02.215

Cutaneous abscess of perineum

L02.216

Cutaneous abscess of umbilicus

L02.219

Cutaneous abscess of trunk, unspecified

L03.311

Cellulitis of abdominal wall

L03.312

Cellulitis of back [any part except buttock]

L03.313

Cellulitis of chest wall

L03.314

Cellulitis of groin

L03.315

Cellulitis of perineum

L03.316

Cellulitis of umbilicus

L03.319

Cellulitis of trunk, unspecified

L03.321

Acute lymphangitis of abdominal wall

L03.322

Acute lymphangitis of back [any part except buttock]

L03.323

Acute lymphangitis of chest wall

L03.324

Acute lymphangitis of groin

L03.325

Acute lymphangitis of perineum

L03.326

Acute lymphangitis of umbilicus

L03.329

Acute lymphangitis of trunk, unspecified

L02.411

Cutaneous abscess of right axilla

L02.412

Cutaneous abscess of left axilla

L02.413

Cutaneous abscess of right upper limb

L02.414

Cutaneous abscess of left upper limb

L02.419

Cutaneous abscess of limb, unspecified

L03.111

Cellulitis of right axilla

L03.112

Cellulitis of left axilla

L03.113

Cellulitis of right upper limb

L03.114

Cellulitis of left upper limb

L03.119

Cellulitis of unspecified part of limb

L03.121

Acute lymphangitis of right axilla

L03.122

Acute lymphangitis of left axilla

L03.123

Acute lymphangitis of right upper limb

L03.124

Acute lymphangitis of left upper limb

L03.129

Acute lymphangitis of unspecified part of limb

L02.31

Cutaneous abscess of buttock

L03.317

Cellulitis of buttock

L03.327

Acute lymphangitis of buttock

L02.415

Cutaneous abscess of right lower limb

L02.416

Cutaneous abscess of left lower limb

L03.115

Cellulitis of right lower limb

L03.116

Cellulitis of left lower limb

L03.125

Acute lymphangitis of right lower limb

L03.126

Acute lymphangitis of left lower limb

L02.811

Cutaneous abscess of head [any part, except face]

L02.818

Cutaneous abscess of other sites

L03.811

Cellulitis of head [any part, except face]

L03.818

Cellulitis of other sites

L03.891

Acute lymphangitis of head [any part, except face]

L03.898

Acute lymphangitis of other sites

L02.91

Cutaneous abscess, unspecified

L03.90

Cellulitis, unspecified

L03.91

Acute lymphangitis, unspecified

L98.3

Eosinophilic cellulitis [Wells]

L01.00

Impetigo, unspecified

L01.01

Non-bullous impetigo

L01.02

Bockhart's impetigo

L01.03

Bullous impetigo

L01.09

Other impetigo

L01.1

Impetiginization of other dermatoses

L05.01

Pilonidal cyst with abscess

L05.02

Pilonidal sinus with abscess

L05.91

Pilonidal cyst without abscess

L05.92

Pilonidal sinus without abscess

L08.9

Local infection of the skin and subcutaneous tissue, unspecified

L21.9

Seborrheic dermatitis, unspecified

L22.

Diaper dermatitis

L20.0

Besnier's prurigo

L20.81

Atopic neurodermatitis

L20.82

Flexural eczema

L20.84

Intrinsic (allergic) eczema

L20.89

Other atopic dermatitis

L20.9

Atopic dermatitis, unspecified

L23.7

Allergic contact dermatitis due to plants, except food

L24.7

Irritant contact dermatitis due to plants, except food

L25.5

Unspecified contact dermatitis due to plants, except food

L55.0

Sunburn of first degree

L55.9

Sunburn, unspecified

L23.9

Allergic contact dermatitis, unspecified cause

L24.9

Irritant contact dermatitis, unspecified cause

L25.9

Unspecified contact dermatitis, unspecified cause

L30.0

Nummular dermatitis

L30.2

Cutaneous autosensitization

L30.8

Other specified dermatitis

L30.9

Dermatitis, unspecified

L27.0

Generalized skin eruption due to drugs and medicaments taken internally

L27.1

Localized skin eruption due to drugs and medicaments taken internally

L27.2

Dermatitis due to ingested food

L42.

Pityriasis rosea

L29.9

Pruritus, unspecified

L60.0

Ingrowing nail

L63.2

Ophiasis

L63.8

Other alopecia areata

L63.9

Alopecia areata, unspecified

L66.3

Perifolliculitis capitis abscedens

L73.1

Pseudofolliculitis barbae

L73.8

Other specified follicular disorders

L74.0

Miliaria rubra

L74.1

Miliaria crystallina

L74.2

Miliaria profunda

L74.3

Miliaria, unspecified

L74.8

Other eccrine sweat disorders

L75.0

Bromhidrosis

L75.1

Chromhidrosis

L75.8

Other apocrine sweat disorders

L70.0

Acne vulgaris

L70.1

Acne conglobata

L70.3

Acne tropica

L70.4

Infantile acne

L70.5

Acne excoriee des jeunes filles

L70.8

Other acne

L70.9

Acne, unspecified

L73.0

Acne keloid

L72.0

Epidermal cyst

L72.2

Steatocystoma multiplex

L72.3

Sebaceous cyst

L72.8

Other follicular cysts of the skin and subcutaneous tissue

L72.9

Follicular cyst of the skin and subcutaneous tissue, unspecified

L50.9

Urticaria, unspecified

M12.9

Arthropathy, unspecified

M22.90

Unspecified disorder of patella, unspecified knee

M22.91

Unspecified disorder of patella, right knee

M22.92

Unspecified disorder of patella, left knee

M23.90

Unspecified internal derangement of unspecified knee

M23.91

Unspecified internal derangement of right knee

M23.92

Unspecified internal derangement of left knee

M25.461

Effusion, right knee

M25.462

Effusion, left knee

M25.469

Effusion, unspecified knee

M25.511

Pain in right shoulder

M25.512

Pain in left shoulder

M25.519

Pain in unspecified shoulder

M25.521

Pain in right elbow

M25.522

Pain in left elbow

M25.529

Pain in unspecified elbow

M25.531

Pain in right wrist

M25.532

Pain in left wrist

M25.539

Pain in unspecified wrist

M25.561

Pain in right knee

M25.562

Pain in left knee

M25.569

Pain in unspecified knee

M25.571

Pain in right ankle and joints of right foot

M25.572

Pain in left ankle and joints of left foot

M25.579

Pain in unspecified ankle and joints of unspecified foot

M25.50

Pain in unspecified joint

M54.2

Cervicalgia

M54.5

Low back pain

M54.14

Radiculopathy, thoracic region

M54.15

Radiculopathy, thoracolumbar region

M54.16

Radiculopathy, lumbar region

M54.17

Radiculopathy, lumbosacral region

M54.89

Other dorsalgia

M54.9

Dorsalgia, unspecified

M54.03

Panniculitis affecting regions of neck and back, cervicothoracic region

M54.04

Panniculitis affecting regions of neck and back, thoracic region

M54.05

Panniculitis affecting regions of neck and back, thoracolumbar region

M54.06

Panniculitis affecting regions of neck and back, lumbar region

M54.07

Panniculitis affecting regions of neck and back, lumbosacral region

M54.08

Panniculitis affecting regions of neck and back, sacral and sacrococcygeal region

M54.09

Panniculitis affecting regions, neck and back, multiple sites in spine

M62.830

Muscle spasm of back

M25.751

Osteophyte, right hip

M25.752

Osteophyte, left hip

M25.759

Osteophyte, unspecified hip

M70.60

Trochanteric bursitis, unspecified hip

M70.61

Trochanteric bursitis, right hip

M70.62

Trochanteric bursitis, left hip

M70.70

Other bursitis of hip, unspecified hip

M70.71

Other bursitis of hip, right hip

M70.72

Other bursitis of hip, left hip

M76.00

Gluteal tendinitis, unspecified hip

M76.01

Gluteal tendinitis, right hip

M76.02

Gluteal tendinitis, left hip

M76.10

Psoas tendinitis, unspecified hip

M76.11

Psoas tendinitis, right hip

M76.12

Psoas tendinitis, left hip

M76.20

Iliac crest spur, unspecified hip

M76.21

Iliac crest spur, right hip

M76.22

Iliac crest spur, left hip

M76.30

Iliotibial band syndrome, unspecified leg

M76.31

Iliotibial band syndrome, right leg

M76.32

Iliotibial band syndrome, left leg

M76.50

Patellar tendinitis, unspecified knee

M76.51

Patellar tendinitis, right knee

M76.52

Patellar tendinitis, left knee

M76.70

Peroneal tendinitis, unspecified leg

M76.71

Peroneal tendinitis, right leg

M76.72

Peroneal tendinitis, left leg

M77.50

Other enthesopathy of unspecified foot

M77.51

Other enthesopathy of right foot

M77.52

Other enthesopathy of left foot

M77.9

Enthesopathy, unspecified

M25.70

Osteophyte, unspecified joint

M65.831

Other synovitis and tenosynovitis, right forearm

M65.832

Other synovitis and tenosynovitis, left forearm

M65.839

Other synovitis and tenosynovitis, unspecified forearm

M65.841

Other synovitis and tenosynovitis, right hand

M65.842

Other synovitis and tenosynovitis, left hand

M65.849

Other synovitis and tenosynovitis, unspecified hand

M65.10

Other infective (teno)synovitis, unspecified site

M65.111

Other infective (teno)synovitis, right shoulder

M65.112

Other infective (teno)synovitis, left shoulder

M65.119

Other infective (teno)synovitis, unspecified shoulder

M65.121

Other infective (teno)synovitis, right elbow

M65.122

Other infective (teno)synovitis, left elbow

M65.129

Other infective (teno)synovitis, unspecified elbow

M65.131

Other infective (teno)synovitis, right wrist

M65.132

Other infective (teno)synovitis, left wrist

M65.139

Other infective (teno)synovitis, unspecified wrist

M65.141

Other infective (teno)synovitis, right hand

M65.142

Other infective (teno)synovitis, left hand

M65.149

Other infective (teno)synovitis, unspecified hand

M65.151

Other infective (teno)synovitis, right hip

M65.152

Other infective (teno)synovitis, left hip

M65.159

Other infective (teno)synovitis, unspecified hip

M65.161

Other infective (teno)synovitis, right knee

M65.162

Other infective (teno)synovitis, left knee

M65.169

Other infective (teno)synovitis, unspecified knee

M65.171

Other infective (teno)synovitis, right ankle and foot

M65.172

Other infective (teno)synovitis, left ankle and foot

M65.179

Other infective (teno)synovitis, unspecified ankle and foot

M65.18

Other infective (teno)synovitis, other site

M65.19

Other infective (teno)synovitis, multiple sites

M65.80

Other synovitis and tenosynovitis, unspecified site

M65.811

Other synovitis and tenosynovitis, right shoulder

M65.812

Other synovitis and tenosynovitis, left shoulder

M65.819

Other synovitis and tenosynovitis, unspecified shoulder

M65.821

Other synovitis and tenosynovitis, right upper arm

M65.822

Other synovitis and tenosynovitis, left upper arm

M65.829

Other synovitis and tenosynovitis, unspecified upper arm

M65.851

Other synovitis and tenosynovitis, right thigh

M65.852

Other synovitis and tenosynovitis, left thigh

M65.859

Other synovitis and tenosynovitis, unspecified thigh

M65.861

Other synovitis and tenosynovitis, right lower leg

M65.862

Other synovitis and tenosynovitis, left lower leg

M65.869

Other synovitis and tenosynovitis, unspecified lower leg

M65.88

Other synovitis and tenosynovitis, other site

M65.89

Other synovitis and tenosynovitis, multiple sites

M67.30

Transient synovitis, unspecified site

M67.311

Transient synovitis, right shoulder

M67.312

Transient synovitis, left shoulder

M67.319

Transient synovitis, unspecified shoulder

M67.321

Transient synovitis, right elbow

M67.322

Transient synovitis, left elbow

M67.329

Transient synovitis, unspecified elbow

M67.331

Transient synovitis, right wrist

M67.332

Transient synovitis, left wrist

M67.339

Transient synovitis, unspecified wrist

M67.341

Transient synovitis, right hand

M67.342

Transient synovitis, left hand

M67.349

Transient synovitis, unspecified hand

M67.351

Transient synovitis, right hip

M67.352

Transient synovitis, left hip

M67.359

Transient synovitis, unspecified hip

M67.361

Transient synovitis, right knee

M67.362

Transient synovitis, left knee

M67.369

Transient synovitis, unspecified knee

M67.371

Transient synovitis, right ankle and foot

M67.372

Transient synovitis, left ankle and foot

M67.379

Transient synovitis, unspecified ankle and foot

M67.38

Transient synovitis, other site

M67.39

Transient synovitis, multiple sites

M62.40

Contracture of muscle, unspecified site

M62.411

Contracture of muscle, right shoulder

M62.412

Contracture of muscle, left shoulder

M62.419

Contracture of muscle, unspecified shoulder

M62.421

Contracture of muscle, right upper arm

M62.422

Contracture of muscle, left upper arm

M62.429

Contracture of muscle, unspecified upper arm

M62.431

Contracture of muscle, right forearm

M62.432

Contracture of muscle, left forearm

M62.439

Contracture of muscle, unspecified forearm

M62.441

Contracture of muscle, right hand

M62.442

Contracture of muscle, left hand

M62.449

Contracture of muscle, unspecified hand

M62.451

Contracture of muscle, right thigh

M62.452

Contracture of muscle, left thigh

M62.459

Contracture of muscle, unspecified thigh

M62.461

Contracture of muscle, right lower leg

M62.462

Contracture of muscle, left lower leg

M62.469

Contracture of muscle, unspecified lower leg

M62.471

Contracture of muscle, right ankle and foot

M62.472

Contracture of muscle, left ankle and foot

M62.479

Contracture of muscle, unspecified ankle and foot

M62.48

Contracture of muscle, other site

M62.49

Contracture of muscle, multiple sites

M62.831

Muscle spasm of calf

M62.838

Other muscle spasm

M60.80

Other myositis, unspecified site

M60.811

Other myositis, right shoulder

M60.812

Other myositis, left shoulder

M60.819

Other myositis, unspecified shoulder

M60.821

Other myositis, right upper arm

M60.822

Other myositis, left upper arm

M60.829

Other myositis, unspecified upper arm

M60.831

Other myositis, right forearm

M60.832

Other myositis, left forearm

M60.839

Other myositis, unspecified forearm

M60.841

Other myositis, right hand

M60.842

Other myositis, left hand

M60.849

Other myositis, unspecified hand

M60.851

Other myositis, right thigh

M60.852

Other myositis, left thigh

M60.859

Other myositis, unspecified thigh

M60.861

Other myositis, right lower leg

M60.862

Other myositis, left lower leg

M60.869

Other myositis, unspecified lower leg

M60.871

Other myositis, right ankle and foot

M60.872

Other myositis, left ankle and foot

M60.879

Other myositis, unspecified ankle and foot

M60.88

Other myositis, other site

M60.89

Other myositis, multiple sites

M60.9

Myositis, unspecified

M79.1

Myalgia

M79.7

Fibromyalgia

M79.601

Pain in right arm

M79.602

Pain in left arm

M79.603

Pain in arm, unspecified

M79.604

Pain in right leg

M79.605

Pain in left leg

M79.606

Pain in leg, unspecified

M79.609

Pain in unspecified limb

M79.621

Pain in right upper arm

M79.622

Pain in left upper arm

M79.629

Pain in unspecified upper arm

M79.631

Pain in right forearm

M79.632

Pain in left forearm

M79.639

Pain in unspecified forearm

M79.641

Pain in right hand

M79.642

Pain in left hand

M79.643

Pain in unspecified hand

M79.644

Pain in right finger(s)

M79.645

Pain in left finger(s)

M79.646

Pain in unspecified finger(s)

M79.651

Pain in right thigh

M79.652

Pain in left thigh

M79.659

Pain in unspecified thigh

M79.661

Pain in right lower leg

M79.662

Pain in left lower leg

M79.669

Pain in unspecified lower leg

M79.671

Pain in right foot

M79.672

Pain in left foot

M79.673

Pain in unspecified foot

M79.674

Pain in right toe(s)

M79.675

Pain in left toe(s)

M79.676

Pain in unspecified toe(s)

M79.89

Other specified soft tissue disorders

M94.0

Chondrocostal junction syndrome [Tietze]

R42.

Dizziness and giddiness

G93.3

Postviral fatigue syndrome

R53.0

Neoplastic (malignant) related fatigue

R53.1

Weakness

R53.81

Other malaise

R53.83

Other fatigue

R21.

Rash and other nonspecific skin eruption

R22.0

Localized swelling, mass and lump, head

R22.1

Localized swelling, mass and lump, neck

R22.30

Localized swelling, mass and lump, unspecified upper limb

R22.31

Localized swelling, mass and lump, right upper limb

R22.32

Localized swelling, mass and lump, left upper limb

R22.33

Localized swelling, mass and lump, upper limb, bilateral

R22.40

Localized swelling, mass and lump, unspecified lower limb

R22.41

Localized swelling, mass and lump, right lower limb

R22.42

Localized swelling, mass and lump, left lower limb

R22.43

Localized swelling, mass and lump, lower limb, bilateral

R22.9

Localized swelling, mass and lump, unspecified