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Edit 90523
Procedure Not Applicable for Reported Diagnosis/Diagnosis Is Not Specific
HIPAA Claim Adjustment Reason Code: 11
Remark Code: N/A
HIPAA Healthcare Claim Status Code: 255
Entity Identifier Code: N/A
Potential Causes:
It was determined that the Procedure Code used does not apply to the Diagnosis Code used after review by the New York State Department of Health.
Solution:
Check the Diagnosis and Procedure Codes entered. Contact the New York State Department of Health. Enter the data in the loop and the segment provided, and resubmit.
| 837 Institutional |
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
Or
Loop 2300, HI (Principal Procedure Information) - (Inpatient of Clinic)
HI01-1 = BR (Code List Qualifier Code)
HI01-2 = Principal Procedure Code (Industry Code)
Or
Loop 2400, SV2 (Institutional Service Line) - (Non-Inpatient)
SV202-1 = HC (Product/Service ID Qualifier)
SV202-2 = Procedure Code – Enter HCPCS procedure code (Product/Service ID) |
| 837 Professional |
Loop 2300 HI (Health Care Diagnosis Code)
HI01-1 = BK (Principal Diagnosis)
HI01-2 = Principal Diagnosis
And
Loop 2400 SV1 (Professional Service)
SV107 -1 = Primary Diagnosis Code Pointer
Loop 2400, SV1 (Professional Service)
SV101-1 = HC (Product/Service ID Qualifier)
SV101-2 = Procedure Code (Product/Service ID) |
Note: There is no diagnosis data required for the Dental transaction.
| 837 Dental |
Loop 2400, SV3 (Dental Service)
SV301-1 = AD (Product/Service ID Qualifier)
SV301-2 = Procedure Code (Product/Service ID) |
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