Stream: CARIN IG for Blue Button®
Topic: C4BB EOB Profiles - Diagnosis Required
Jason Buys (Apr 12 2021 at 17:41):
We have a client who does not have diagnosis data with their claims. I see that in the C4BB professional profile this is set as required, how should handle this?
Corey Spears (Apr 13 2021 at 04:26):
The CARIN BB Implementation Guide is meant to reflect data that is included with claims transactions. Do you have more information on your use case or could you join us in a call to discuss?
Ngan MacDonald (Apr 16 2021 at 00:31):
@Corey Spears Medicaid programs for long term care at home for the elderly may not have a diagnosis related to it because it's being billed for things like meal service. Like @Jason Buys asked, how do we code this if there's no diagnosis on the claim. @Pat Taylor @Amol Vyas Do you guys have thoughts on this?
Daniel Venton (Apr 16 2021 at 13:36):
Isn't the patient in the LTC facility for a reason? Dementia - that's a diagnosis. Why is the LTC facility billing for room and board? Diagnosis - Dementia.
Pat Taylor (Apr 21 2021 at 17:49):
@Ngan MacDonald @Jason Buys My understanding is that all claim formats require at least one diagnosis code. What format are the claims are being billed on? @Amol Vyas
Ngan MacDonald (Apr 22 2021 at 14:09):
@Daniel Venton No, the patient is frail. In Wisconsin, there is Medicaid programs directed towards keeping patients in their home. There are a host of non-diagnostic services (house cleaning, meals on wheels, etc. that are not tied to a specific diagnosis. @Pat Taylor Not all claim formats require a diagnosis in this case. The patient is assessed as frail and need additional support. @Amol Vyas Have you guys dealt with implementors for Medicaid Care Organizations that are more social type of support than medical support?
Daniel Venton (Apr 22 2021 at 14:28):
Wouldn't that fall under:
2021 ICD-10-CM Diagnosis Code R54
Age-related physical debility
2016 2017 2018 2019 2020 2021 Billable/Specific Code Adult Dx (15-124 years)
R54 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
The 2021 edition of ICD-10-CM R54 became effective on October 1, 2020.
This is the American ICD-10-CM version of R54 - other international versions of ICD-10 R54 may differ.
ICD-10-CM Coding Rules
R54 is applicable to adult patients aged 15 - 124 years inclusive.
Applicable To
Frailty
Old age
Senescence
Senile asthenia
Senile debility
Ngan MacDonald (Apr 22 2021 at 15:01):
If we don't have the diagnosis on the claim, so I'm not saying that there are none applicable, just a question of what happens if we don't have it.
Daniel Venton (Apr 22 2021 at 15:15):
Depends on the consumer of the resource, do they care if the diagnosis is populated.
Payor, probably cares. Member, probably not. Validator, cares.
Gail Kocher (Apr 22 2021 at 18:18):
@Ngan MacDonald Could you provide the actual documentation where you think a claim format does not require a diagnosis code? Both the 837 Institutional and 837 Professional claim absolutely require at least one diagnosis code. It is not even a situational data element. The UB-04 manual also requires at least one diagnosis on the UB-04 and the 1500 instruction manual directs the diagnosis be reported.
Ngan MacDonald (Apr 22 2021 at 18:57):
@Gail Kocher I'm not trying to say that a claim format doesn't require a diagnosis code, I'm trying to introduce a situation in which claims are sent in non-EDI format, are paid for by Medicaid in the state and in this situation, the diagnosis code is not required.
Gail Kocher (Apr 22 2021 at 19:00):
@Ngan MacDonald The paper claim forms also require diagnosis codes.
Ngan MacDonald (Apr 29 2021 at 15:08):
@Gail Kocher Medicaid doesn't require a diagnosis code. They are phasing in zcodes for SDOH type of situations, but it's not rolled out.
Anil Samuel (Sep 23 2021 at 15:46):
PlannetNetwork Profile definition:
A Network refers to a healthcare provider insurance network. A healthcare provider insurance network is an aggregation of organizations and individuals that deliver a set of services across a geography through health insurance products/plans. A network is typically owned by a payer.
In the PlanNet IG, individuals and organizations are represented as participants in a PLan-Net Network through the practitionerRole and Plan-Net-organizationAffiliation resources, respectively.
Question:
1.Do we create one PlannetNetwork profile for Medicaid? Yes, and by extension the Plannet Insurance profile.
If so, how do we identify Medicaid for the data elements needed to create the PlannetNetwork profile (which is based on the Organization profile)?
For example, Organization ID.
Medicaid does not have a provider ID. How do we identify Medicaid?
Corey Spears (Sep 23 2021 at 15:58):
@Anil Samuel, Your question does not match the topic of this thread nor the scope of the #CARIN IG for Blue Button® stream.
Perhaps you could post it in the #Da+Vinci+PDex+Plan-Net stream to get to the right audience?
Last updated: Apr 12 2022 at 19:14 UTC
