5.3.1 Diagnosis CodingThe Texas Medicaid Program requires providers to provide International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes on their claims. The only diagnosis coding structure accepted by the Texas Medicaid Program is the ICD-9-CM. Diagnosis codes must be to the highest level of specificity available. In most cases a written description of the diagnosis is not required. ICD-9-CM evaluation and management codes are not payable as a primary diagnosis. All V-codes are acceptable as diagnoses except the following nonspecific codes:
These nonspecific codes can be used for a general description but may not be referenced to a specific procedure code. Generally, V-codes are supplementary and are used only when the client's condition cannot be classified to categories 001 through 999. The use of observation diagnosis codes V718 and V717 results in claim denial with EOB 00543, "Documentation insufficient to verify medical necessity. Resubmit the claim with signed claim copy, R&S report copy, and complete documentation of medical necessity." Independent laboratories, pathologists, and radiologists are not required to provide diagnosis codes except when billing for procedures identified under "Diagnosis Requirements" . |
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Texas Medicaid & Healthcare Partnership CPT only copyright 2007 American Medical Association. All rights reserved. |
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