Edit 00227

Primary Diagnosis Indicates Abortion / Abort Code Invalid

HIPAA Claim Adjustment Reason Code: 50
            Remark Code: N/A
HIPAA Healthcare Claim Status Code: 254
            Entity Identifier Code: N/A

Potential Causes:
The Primary Diagnosis Code indicates abortion but the Abortion Code is not for an abortion.

Solution:
Please check the Principal Diagnosis Code and the Abortion Code to ensure that the correct information was entered.

Institutional:
Diagnosis Code: HIPAA requires a Principal Diagnosis for most Institutional claims. There are a large number of Institutional type claims that are not Diagnosis related. Some examples are Child Care, Managed Care, Wavered Services Claims - of which there are 4 different types. NYSDOH will accept Code 7999 for these types of claims.

Abortion Code: Please refer to the New York State Medicaid 837I Supplemental Companion Guide, Section “Condition Codes”. Only codes with specific impact upon the NYS Medicaid program have been provided. (Please reference the NUBC manual for a complete listing of Condition Codes. The NUBC manual can be found at www.nubc.org).

Professional:
Abortion Code: Please refer to the New York State Medicaid 837P Supplemental Companion Guide, Section “Abortion Condition Codes”. NYSDOH requires Abortion Condition Codes to be reported for all abortion related services as follows: Loop 2300, NTE, NTE01 and NTE02.

(If the services being reported were rendered under a Special Program this must be indicated as follows: Loop 2400, CLM, CLM12. Please refer to the New York State Medicaid 837P Supplemental Companion Guide, Section “Special Program Code”.)

Diagnosis Code: NYSDOH expects to receive the Primary Diagnosis Code pointer in Loop 2400, SV2, SV107-1. NYSDOH will be unable to determine the appropriate Diagnosis Code without this pointer.

Enter the data in the loops and segments provided and resubmit.