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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 6: Claims Filing : 6.3 Coding : 6.3.1 Diagnosis Coding

Texas Medicaid 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 Texas Medicaid 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.
All diagnosis codes that are submitted on a claim must be appropriate for the age of the client as identified in the ICD-9-CM description of the diagnosis code. Claims that are denied because one or more of the diagnosis codes submitted on the claim are not appropriate for the age of the client may be appealed with the correct diagnosis code or documentation of medical necessity to justify the use of the diagnosis code.
ICD-9-CM codes for external causes of injury and poisoning (E codes) and morphology of neoplasms (M codes) are not valid 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 code V717 results in claim denial with explanation of benefits (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 unless otherwise stated in other sections of this manual.

Texas Medicaid & Healthcare Partnership
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