Claim edit: Invalid primary diagnosis on Medicare chiropractic claims

Stedi now rejects 837P professional claims that are billed to Medicare Part B for chiropractic services when the primary diagnosis doesn’t indicate subluxation – a partial dislocation of a spinal joint.

Medicare requires the primary diagnosis on a chiropractic claim to indicate subluxation. In ICD-10-CM, this is represented by the M99.0x family of diagnosis codes: M99.00-M99.05.

Medicare Part B claims submitted with a non-subluxation primary diagnosis may be rejected by the Medicare Administrative Contractor (MAC) payer, which can cause delays.

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

When this edit applies
A claim will fail this edit when all of the following are true:

• The claim is billed to a MAC payer.

• The claim includes a service line with one of the following Chiropractic Manipulative Treatment (CMT) procedure codes: 98940, 98941, or 98942.

• The claim’s primary diagnosis code is not within the M99.00-M99.05 range (inclusive).

  • In raw X12, the primary diagnosis is the first diagnosis code in HI (Health Care Diagnosis Code) of Loop 2300 (Claim Information).

  • In the JSON professional claims submission endpoint, the primary diagnosis is in the diagnosisCode field of the first object in the claimInformation.healthCareCodeInformation array.
    Note: Do not include decimal points in the diagnosis code.

  • In the professional claim form, the primary diagnosis is the first diagnosis code in Field A of Box 21 – Diagnosis or nature of illness or injury.

Rejection errors
If you submit a claim that fails the edit 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 includes error details in the errors array:

{
  "errors": [
    {
      "code": "33",
      "description": "Chiropractic claims submitted to Medicare must have a primary diagnosis that lists the precise level of subluxation. 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 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.