Diagnoses on a CMS-1500 Claim Form vs. Diagnosis “Pointers”
Here’s what you should know to help reduce denials
What is the difference between the diagnoses on a CMS-1500 claim form and the diagnosis “pointers” associated with each CPT® code on a CMS-1500 claim form?
A diagnosis code reflects the medical diagnosis that has been made by the provider and tells the payer why a service for which reimbursement is sought was performed. The diagnosis code must also support the medical necessity, and a failure to provide an appropriate code can be the source of a denial if the code used doesn’t support the medical necessity of the service performed.
The diagnosis “pointers” connect the medical diagnosis made by the provider to each CPT® code that is billed. When a CPT code is billed, the provider must connect or “point” the diagnosis to each procedure performed to treat the specific diagnosis, so at least one pointer per CPT code is required and the total number of diagnosis pointers per CPT code are limited to four (4). This means if a provider has more than 4 diagnosis codes for one CPT billed (i.e., procedure or treatment performed), the provider must select only four (4) diagnoses to relate to each such CPT.
In general, this means that the provider should identify the four most important or serious conditions or diagnoses that a procedure is intended to treat, which should be listed in order of severity and specifically related to the procedure code they are pointed to.
Total diagnoses and diagnosis pointers are recorded differently on the claim form. Specifically, diagnosis codes are found in box 21 A-L on the claim form and should be entered using ICD-10-CM codes. The total number of diagnoses that can be listed on a single claim are twelve (12). The diagnosis pointers are located in box 24E on the paper claim form for each CPT code billed. The line identifiers from Box 21 (A-L) should be related to the lines of service in 24E by the letter of the line.
Additional Resources
These requirements can be found in the Medicare Claims Processing Manual: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf (see pp. 14-17).
You can also find instructions in the CMS-1500 Claim Form/American National Standards Institute (ANSI) Crosswalk for Paper/Electronic Claims.
The health insurance claim form is approved by National Uniform Claim Committee (NUCC). You can find the NUCC Instruction Manual at: www.nucc.org. Approved OMB-0938-1197 FORM 1500 (02-12).
Ronda Tews, CPC, CHC, CCS-P
DIRECTOR OF BILLING AND CODING COMPLIANCE
Ronda Tews, Certified Professional Coder (CPC), Certified in Healthcare Compliance (CHC), and Certified Coding Specialist-Physician (CCS-P), is the director of billing and coding compliance at Modernizing Medicine® and brings over two decades of robust healthcare compliance experience to the organization. In her current role, she develops and manages the billing and coding compliance program for the company. Ronda performs billing and coding compliance audits among other related functions while maintaining knowledge of current regulatory and compliance guidance.
Prior to her time at Modernizing Medicine, Ronda held various roles such as managing provider compliance for a large health plan in Oklahoma and creating a fraud, waste and abuse program. Ronda’s duties have consisted of conducting E/M audits on physicians and mid-level providers, establishing internal auditing and monitoring, as well as teaching basic coding classes to co-workers and providing E/M documentation training to physicians and mid-level providers. She has also implemented compliance education and training programs, managed the Compliance Report Line as well as compliance auditing and monitoring. Ronda also provided coding and documentation education at Missouri State University to the physician assistant students on an annual basis. Ronda has held various roles such as serving as a Quality Improvement analyst and working as a corporate compliance project manager for a large Mid-Western health system.
Ronda founded the Springfield, MO AAPC chapter where she served as the president and treasurer. She remains very active in the industry as she writes articles for industry publications and can be found speaking at conferences. Connect with Ronda on LinkedIn.