Claim edit: All invalid ICD-10-CM diagnosis codes are now returned at once

Stedi's claim edit for invalid ICD-10-CM diagnosis codes now returns all invalid codes in the rejection's error message. The edit applies to 837P professional and 837I institutional claims.

Previously, if a claim had multiple invalid codes, only one was returned per rejection. To fix all the invalid codes, you had to correct and resubmit the claim multiple times – once for each invalid code.

How the edit works

In healthcare claims, diagnosis codes describe what’s wrong with the patient. HIPAA requires that professional and institutional claims only use valid, billable ICD-10-CM codes as diagnosis codes.

Diagnosis codes

Stedi previously introduced an edit for invalid ICD-10-CM diagnosis codes. The edit rejects a professional or institutional claim when any diagnosis code is:

• Not a valid ICD‑10‑CM code.
  For example, if the code is misspelled or doesn’t exist in the official ICD-10-CM code list.
  
  

• A non-billable ICD‑10‑CM code.
  Some ICD-10-CM codes are categories. They cover a broad diagnostic grouping rather than a specific condition. For example, E11 (Type 2 diabetes mellitus) is a category header.
  
  By themselves, category headers aren’t considered billable codes. They’re not specific enough to describe the exact condition or encounter being billed. A billable ICD-10-CM code must include both a category and a subcategory, such as E11.9 (Type 2 diabetes mellitus without complications).
  
  

• Not valid for the claim’s dates of service.
  Updates to the ICD-10-CM code set are published each year. If a claim uses a code that wasn’t valid on the dates of service, Stedi rejects it.
  
  For example, Z11.52 (“Encounter for screening for COVID-19”) became effective on October 1, 2021. A claim with a date of service before that date would be rejected because the code wasn’t valid at the time.

This edit catches these issues before the claim reaches the payer. It prevents payer rejections, which are slower and delay payment for the provider.

Rejection errors

If you submit a claim using Stedi's Claim Submission API endpoints and the claim fails the edit, you'll get back an error response in real time. The response includes details in the errors array:

{
  "errors": [
    {
      "code": "33",
      "description": "Invalid ICD-10-CM Diagnosis Code. All submitted diagnosis codes must be valid per the ICD-10 manual. Diagnosis code(s), XY9999, ZZ0000, do not exist in the code set. Correct and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

{
  "errors": [
    {
      "code": "33",
      "description": "Invalid ICD-10-CM Diagnosis Code. All submitted diagnosis codes must be valid per the ICD-10 manual. Diagnosis code(s), XY9999, ZZ0000, do not exist in the code set. Correct and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

{
  "errors": [
    {
      "code": "33",
      "description": "Invalid ICD-10-CM Diagnosis Code. All submitted diagnosis codes must be valid per the ICD-10 manual. Diagnosis code(s), XY9999, ZZ0000, do not exist in the code set. Correct and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

If you submit a claim using SFTP and the claim fails the edit, Stedi will reject the claim with a 277CA claim acknowledgment. The acknowledgment will include a related claim status category code, claim status code, and error message:

STC*A7>700*[DATE]*U*[AMOUNT]******A7>255**Invalid ICD-10-CM Diagnosis Code. All submitted diagnosis codes must be valid per the ICD-10 manual. Diagnosis code(s), XY9999, ZZ0000, do not exist in the code set. Correct and resubmit

STC*A7>700*[DATE]*U*[AMOUNT]******A7>255**Invalid ICD-10-CM Diagnosis Code. All submitted diagnosis codes must be valid per the ICD-10 manual. Diagnosis code(s), XY9999, ZZ0000, do not exist in the code set. Correct and resubmit

STC*A7>700*[DATE]*U*[AMOUNT]******A7>255**Invalid ICD-10-CM Diagnosis Code. All submitted diagnosis codes must be valid per the ICD-10 manual. Diagnosis code(s), XY9999, ZZ0000, do not exist in the code set. Correct and resubmit