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Edit 000792
Diagnosis Related Group (DRG) Equals 470 (Group was unable to determine a valid DRG)
HIPAA Claim Adjustment Reason Code: 16
Remark Code: M52
HIPAA Healthcare Claim Status Code: 189
Entity Identifier Code: N/A
Potential Causes:
On an Outlier Claim (Rate Code 2956 or 2958), the Admission Date and Beginning Date of Service cannot be the same. When rate Code 2956/2958 is used, the From Date of Service must be after the Admission date. (The Beginning Date of Service must be after the DRG High Trim Point for an Outlier Claim and therefore it must also be after the Admission Date.)
Solution:
Verify that the claim being submitted is for the Outlier portion of the claim. If the claim is not for the Outlier portion of the claim then resubmit with the proper Rate Code. Check the Admission Date to ensure the correct Admission Date was entered. Check the From Date of Service to ensure the correct from Date was entered. Enter the data in the loop and the segments provided, and resubmit.
| 837 Institutional |
Loop 2300, DTP (Statement Dates)
DTP01 = 434 (Date/Time Qualifier)
DTP02 = RD8 (Date Time Period Qualifier)
DTP03 = Format CCYYMMDD-CCYYMMDD (Date Time Period)
And
Loop 2300, DTP (Admission Date/Hour)
DTP01 = 435 (Admission)
DTP02 = DT (Date and Time expressed in Format CCYYMMDDHHMM)
DTP03 = Admission Date and Hour
And
Loop 2300, HI (Value Information) - (Inpatient of Clinic)
HI01-1 = BE (Value)
HI01-2 = 24 (Value Code)
HI01-5 = four digit Rate Code (monetary amount)
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