New claim edit: A sequela code can’t be the primary ICD-10-CM diagnosis code

Stedi now rejects 837P professional and 837I institutional claims that list a sequela code as the only or primary ICD-10-CM diagnosis code.

ICD-10-CM diagnosis codes

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. For example, M54.5 is the ICD-10-CM code for “Chronic low back pain.”

A claim can include multiple diagnosis codes, listed in order of importance. The primary diagnosis code is in position 1, the next is in position 2, and so on.

Sequela codes

A sequela code is an ICD-10-CM diagnosis code used to describe a condition that remains after an earlier injury or illness has healed.

For example, M48.40XS (Fatigue fracture of vertebra, site unspecified, sequela of fracture) is a sequela code. Sequela codes always have S as the seventh character.

How the edit works

ICD-10-CM guidelines disallow a sequela code from being used as the primary or only diagnosis on professional or institutional claims. If it is, the payer may reject the claim, which can delay payment for the provider.

This edit – the industry term for an automated validation rule – catches the issue before the claim reaches the payer.

A sequela code can still be billed, as it provides additional context for the payer on why the patient has the current conditions. But those current conditions must be billed as the primary diagnosis, which describes the primary reason for service.

Rejection errors

If you submit a claim that fails the edit using Stedi’s JSON or X12 Claim Submission API endpoints, you’ll get back an error response in real time. The response includes error details in the errors array:

{
  "errors": [
    {
      "code": "33",
      "description": "Invalid use of Sequela Diagnosis code. The submitted diagnosis code, M48.40XS, is a sequela diagnosis (7th character \"S\") and cannot be used as the primary or only diagnosis on a claim. Correct and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

If you submit a claim that fails the edit using SFTP, 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:N255*[DATE]*U*[AMOUNT]********Invalid use of Sequela Diagnosis code. The submitted diagnosis code, M48.40XS, is a sequela diagnosis (7th character "S") and cannot be used as the primary or only diagnosis on a claim. Correct and resubmit

Resolution tip

In most cases, you can pass this edit by reordering the diagnosis codes so the current condition comes first and the sequela code(s) are listed afterward.

For example, M54.5 (Chronic low back pain) should be listed before the sequela, M48.40XS (Fatigue fracture of vertebra, site unspecified, sequela of fracture). Sequela codes should always accompany a preceding diagnosis code.