HCC Risk Coding and Claim limitations

edited May 2017 in Part B Archive
We are focusing on HCC risk coding on our Medicare and MA populations this year (as many are) and are struggling with the limitation of only 4 diagnosis codes going to the claim. Has anyone found a way to overcome this struggle and how are you doing this to get all of the encounter diagnosis to the claim/bill?

Thank you for your help!

Elizabeth Wineland, RN, MSN, CPHQ
Coordinator, UnityPoint Clinic Clinical Excellence
Quality and Payer Metrics/Performance Improvement

UnityPoint Clinic Methodist|Proctor
120 NE Glen Oak Avenue, Suite 300
Peoria, Illinois 61603

(309) 671-2583 Office
(309) 636-4129 Fax
(309) 648-7087 Mobile



  • The electronic 837P file has up to 12 d/x codes you can populate. We use EPIC PB PM system and use Emdeon as our clearinghouse and ALL the diagnosis codes are being transmitted and received by the payers.

    Jorge R Quintero, MHA, CRCE-P
    Manager, Medical and Financial Management
    Martin Health System
    Office Main: 772-223-5945, ext 14925
    Office Direct: 772-223-4925
    Fax: 772-223-5646
    E-mail: Jorge.quintero@martinhealth.org

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  • Beth,
    Does your practice use a computer system claims electronically with more than 4 dx? Or do you use a clearinghouse that will capture more than 4 dx? We have a computer system that allows us to bill electronically up to 12 dx. Or is a problem with one line item only allowing you to submit 4?

    Jill Peck
    Billing Coordinator
    Physician Practice Management
    St Joe Mercy Chelsea
    tel: 734-593-5728 fax: 734-475-6819
    email: jill.peck@stjoeshealth.org

    Facebook / Twitter


  • edited May 2017
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    The best way to understand this is to look at the paper CMS1500 form.

    12 diagnoses *per claim* (and claims can split for one date of service if
    more than one location is needed to bill properly)

    Up to 4 diagnosis pointers per line item.

    Up to 6 line items per claim.

    I have found software design can behoove the understanding on what can be
    recorded and transmitted.

    Karen A. Hurley, BS, CMM, CPC, CNA

    President, HPMSI

    PO Box 409

    Parrish, FL 34219-0409

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com

    Since 1996, Celebrating 20 years of Service to Physicians

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