Diagnosis Code Specificity

Blue Cross requires diagnosis code specificity when filing claims. It is important to file “ALL” applicable diagnosis codes to the highest degree of specificity. Use the following specificity rules for filing claims: • Always report the most specific diagnosis codes. Example: Only use 3-digit ICD-10 codes when 4-digit codes are not available and 4-digit codes when 5-digit codes are not available in a particular category. Always report the most specific codes.

• Always include ALL related diagnoses, including chronic conditions you are treating the member for.

• Always include an additional code when required to provide a more complete picture. For example, in etiology/manifestation coding, the underlying condition is coded first followed by the manifestation.

• Medical records must support ALL diagnosis codes on claims.

• Filing claims with NOS (not otherwise specified) and NEC (not elsewhere classified) diagnosis codes is not preferred. Filing claims with NOS and NEC codes delays claim processing and may result in Blue Cross requesting medical records. It may also result in delayed payment and possible payment reductions.

• Reporting a header code on a claim is considered to be an incomplete code and the claim will be returned to the provider as “incomplete.”



Provider Access to Medical Code Editing Section on iLinkBLUE

From the Home Page of iLinkBLUE, click on “Medical Code Editing” section on the menu on the left.

• The Clear Claim Connection link connects to a disclaimer page, then to Clear Claim Connection (C3), a Web-based code auditing reference tool designed to audit and evaluate code combinations. C3 is a self-service inquiry tool to help reduce manual inquiries and time consuming appeals. C3 also indicates whether or not a CPT, modifier or CPT/modifier combination is valid for the date of service entered on the inquiry.