Introducing claim edits for invalid diagnosis codes

Stedi now rejects 837P professional claims and 837I institutional claims with an invalid diagnosis code.

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.

What the edits check
Stedi has introduced new edits – the healthcare industry’s term for automated validation rules – to help ensure claims include valid diagnosis codes.

The new edits reject 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 now 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.

If you submit a claim that fails the edits using Stedi’s claim submission APIs or professional claim form, you’ll get back an error message in real time. If you’re using a JSON API endpoint, the response include error details in the errors array:

{
  "errors": [
    {
      "code": "33",
      "description": "The ICD-10 code E11 submitted does not meet the level of specificity needed. The Diagnosis code is a header and not valid for HIPAA transactions. Please resubmit with a more specific ICD-10.",
      "followupAction": "Please Correct and Resubmit"
    }
  ],
  ...
}

If you submit a claim that fails the edits using SFTP, Stedi will reject the claim with a 277CA claim acknowledgment. The acknowledgment will contain a related claim status category code, claim status code, and error message. You can use the error message to correct and resubmit the claim.