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Edit 00160
Secondary Diagnosis Invalid for Sex of Recipient
HIPAA Claim Adjustment Reason Code: 10
Remark Code: N/A
HIPAA Healthcare Claim Status Code: 86
Entity Identifier Code: N/A
Potential Causes:
Some Diagnosis Codes are gender specific. The gender associated with this diagnosis code did not match the gender of the Recipient. This edit applies to the Secondary Diagnosis Code on Professional Claims and the Admitting Diagnosis Code on Inpatient claims.
Solution:
Check the Diagnosis Code entered to ensure the correct Diagnosis Code was used. Refer to the ICD 9 Coding Manual for the gender associated with the Diagnosis Code. Check the Recipient ID entered on the claim to ensure the correct Recipient ID number was used. Verify the sex of the Recipient on MEVS. If the sex of the recipient is incorrect, contact the Local Department of Social Services. Enter the data in the loop and the segment provided, and resubmit
Recipient ID Number for Institutional and Professional:
| 837 Institutional and 837 Professional |
Loop 2010BA, NM1 (Subscriber Name)
NM108 = MI (Identification Code Qualifier)
NM109 = Recipient ID number (Identification Code) |
| 837 Professional |
Loop 2300 HI (Principal, Admitting, E-Code and Patient Reason For Visit Diagnosis Information)
HI01-1 = BK (Principal Diagnosis)
HI01-2 = ICD-9-CM or 7999 |
| 837 Dental |
Loop 2300 HI (Health Care Diagnosis Code)
HI02-1 = BF (Secondary Diagnosis)
HI02-2 = Secondary Diagnosis (ICD9-CM)
And
Loop 2400 SV1 (Professional Service)
SV107 -2 = Secondary Diagnosis Code Pointer |
Note: Diagnosis Code: NYSDOH expects to receive the Primary Diagnosis Code pointer in Loop 2400, SV1, and SV107 -2. NYSDOH will be unable to determine the appropriate Diagnosis Code without this pointer.
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