Claim edit: ICD-10 diagnosis code with pre-implementation service date
Stedi now rejects 837P professional, 837I institutional, and 837D dental claims that pair an ICD-10-CM diagnosis code with a service date before October 1, 2015.
Service dates
In a claim, a service line represents billing for a specific service, such as an office visit or X-ray. The date of service, also called the service date, is the date the service was performed.
| Claim type | JSON API field | X12 element |
|---|---|---|
| 837P professional | claimInformation.serviceLines[].serviceDate | DTP-03 (Date Time Period) of Loop 2400 (Service Line) with qualifier 472 (Service) |
| 837I institutional | claimInformation.serviceLines[].serviceDate | DTP-03 (Date Time Period) of Loop 2400 (Service Line) with qualifier 472 (Service) |
| 837D dental | claimInformation.serviceLines[].serviceDate | DTP-03 (Date Time Period) of Loop 2400 (Service Line) with qualifier 472 (Service) |
Diagnosis codes
Diagnosis codes describe what's wrong with the patient. For example, I10 is the ICD-10-CM code for essential (primary) hypertension.
For services on or after October 1, 2015, HIPAA requires that claims use valid, billable ICD-10-CM codes as diagnosis codes. For services before that date, ICD-9-CM diagnosis codes were used.
| Claim type | JSON API field | X12 element |
|---|---|---|
| 837P professional | claimInformation.healthCareCodeInformation[].diagnosisCode | HI01-2 (Industry Code) of HI segment in Loop 2300 (Health Care Diagnosis Code) |
| 837I institutional | claimInformation.principalDiagnosis.principalDiagnosisCode (principal diagnosis), claimInformation.otherDiagnosisInformationList[][].otherDiagnosisCode (other diagnosis) | HI01-2 (Industry Code) of HI segment in Loop 2300 (Health Care Diagnosis Code) |
| 837D dental | claimInformation.healthCareCodeInformation[].diagnosisCode | HI01-2 (Industry Code) of HI segment in Loop 2300 (Health Care Diagnosis Code) |
Each diagnosis code is paired with a qualifier identifying its code set and position. ICD-10-CM codes use ABK (principal diagnosis) or ABF (other diagnosis). ICD-9-CM codes use BK or BF.
For example, the ICD-10-CM code E11.9 (Type 2 diabetes mellitus without complications) submitted as the principal diagnosis carries the ABK qualifier.
| Claim type | JSON API field | X12 element |
|---|---|---|
| 837P professional | claimInformation.healthCareCodeInformation[].diagnosisTypeCode | HI01-1 (Code List Qualifier Code) of HI segment in Loop 2300 (Health Care Diagnosis Code) |
| 837I institutional | claimInformation.principalDiagnosis.qualifierCode (principal diagnosis), claimInformation.otherDiagnosisInformationList[][].qualifierCode (other diagnosis) | HI01-1 (Code List Qualifier Code) of HI segment in Loop 2300 (Health Care Diagnosis Code) |
| 837D dental | claimInformation.healthCareCodeInformation[].diagnosisTypeCode | HI01-1 (Code List Qualifier Code) of HI segment in Loop 2300 (Health Care Diagnosis Code) |
How the edit works
If you submit a claim with an ICD-10-CM diagnosis code (qualifier ABK or ABF) and any service line has a date of service before October 1, 2015, the payer may reject the claim.
This edit catches the issue 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 Diagnosis for Date of Service. ICD-10 diagnosis codes (qualifier ABK, ABF) are valid for dates of services on or after the implementation date of 10/01/2015. Prior to the implementation date, ICD-9 codes (qualifier BK, BF) are typically used. 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]********Invalid ICD-10 Diagnosis for Date of Service. ICD-10 diagnosis codes (qualifier ABK, ABF) are valid for dates of services on or after the implementation date of 10/01/2015. Prior to the implementation date, ICD-9 codes (qualifier BK, BF) are typically used. Correct and resubmit.~