Reminder: Follow ICD-10 guidelines and code to the highest degree of specificity

As a reminder, when billing for both professional and facility services, it’s important to code to the highest level of specificity.

At Priority Health, we use several coding and billing resources to align correct coding guidelines for accurate claims processing. This includes criteria defined by ICD-10 coding guidelines. See our General Coding Policy, available on the Billing & coding policies page in our Provider Manual, for details.

Clinical edits are controls aligned with coding guidelines or industry standard principles to flag inappropriate coding practices, inaccurate billing or duplication of services.

Why are we issuing this reminder?

On Aug. 16, 2022, we issued a notice to the provider network for a new clinical edit for ICD-10’s Excludes1 criteria, which details diagnosis codes that shouldn’t be reported together because the two codes can’t occur at the same time.

In October 2022, the edit was turned on for professional claims. On June 4, 2024, we’ll implement the edit for inpatient and outpatient facility claims as well.

What do you need to know?

You can reference the ICD-10 coding manual’s Excludes Notes section for more detail and examples. You may also correct and resubmit denied claims with accurately coded diagnosis codes.