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Edit 00738
ICD-9-CM Diagnosis Code on Physician Claim Not on File
HIPAA Claim Adjustment Reason Code: 167
Remark Code: N/A
HIPAA Healthcare Claim Status Code: 255
Entity Identifier Code: N/A
Potential Causes:
The Diagnosis Code entered on the claim is not a valid Diagnosis code. Medicaid requires the 4th and 5th digit sub-classification when available.
Solution:
Check the Diagnosis Code and the Diagnosis Code Pointer to ensure they were entered correctly. Check the Diagnosis Code that was entered on the claim in the ICD 9 Diagnosis Manual to ensure it is a valid code. If the code used requires a 4 th or 5 th digit, ensure the 4 th and/or 5 th digit are included on the claim. Enter the data in the loop and the segment provided, and resubmit.
| 837 Professional |
Loop 2300 HI (Health Care Diagnosis Code)
HI01-1 = BK (Principal Diagnosis)
HI01-2 = Principal Diagnosis
Loop 2400 SV1 (Professional Service)
SV107 -1 = Primary Diagnosis Code Pointer |
Note: Diagnosis Code: NYSDOH expects to receive the Primary Diagnosis Code pointer in Loop 2400, SV1, SV107 -1. NYSDOH will be unable to determine the appropriate Diagnosis Code without this pointer.
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