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Edit 000790 HIPAA Claim Adjustment Reason Code: 16 Potential Causes: Solution: If the patient went to an Alternate Level of Care (ALC) before the high trim day, then the Occurrence Code 75 must be used. (The Occurrence Code 75 replaces the proprietary discharge status code 31.) Status Code 31 was used to indicate the patient went to ALC before the day of high trim and allowed the DRG Inlier claim to have an end Date of Service that is before the high trim point). If the patient did not go to ALC before the high trim point, then check the DRG assigned to the claim. If the DRG assigned is different than the anticipated DRG, then check the Diagnosis and Procedure Codes entered to ensure the correct codes were used. If all the coding is correct then contact the New York State Department of Health as to why the DRG grouped differently than what was expected. If the DRG assigned to the claim is correct, then check the high trim point for the DRG to ensure the claim is billed according to that high trim point. It is also a possibility that the Through Date of Service may have been entered incorrectly. Check the through Date of Service entered to ensure the correct date was used as it related to the high trim pint for the DRG. (Note: This edit was in program remediation involving the use of Occurrence Code 75 and was fixed on 12/2/04. If the denial was before 12/2 and the code 75 was used please resubmit the claim)
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