CLAIMS SUBMISSION 4 4.1 OVERVIEW .................................................................................................. 4-3 4.2 METHOD OF SUBMITTING CLAIMS .......................................................... 4-3 Medical Claims Electronic Data Transfer ..................................................... 4-3 Electronic Data Transfer (EDT) .................................................................... 4-4 4.3 PROCESS TO SUBMIT CLAIMS ................................................................. 4-5 4.4 SUBMISSION OF CLAIMS .......................................................................... 4-5 HCP Claim ................................................................................................... 4-5 WSIB Claim .................................................................................................. 4-6 RMB Claim ................................................................................................... 4-6 Patient Information ....................................................................................... 4-7 Coding Requirements .................................................................................. 4-8 Cut-Off Date for Claims Submission ............................................................ 4-8 Resubmission of Unpaid Claims .................................................................. 4-9 Claims Requiring Documentation ................................................................. 4-9 Claims Submission Resource Manual for Physicians 4.5 REPORTS .................................................................................................... 4-9 File Reject Message ..................................................................................... 4-9 Batch Edit Report ......................................................................................... 4-9 Claims Error Report ................................................................................... 4-10 Split Claims Error Report............................................................................ 4-11 Remittance Advice Report (RA) ................................................................. 4-11 Group RA Split/Extract ............................................................................... 4-11 OBEC Response File ................................................................................. 4-11 Governance Reports .................................................................................. 4-12 Primary Care Reports ................................................................................ 4-12 Enrolment/Consent Outside Use Report .................................................... 4-12 Enrolment/Consent Patient Summary Report ............................................ 4-12 4.6 RECONCILIATION AND PAYMENT .......................................................... 4-12 4.7 INQUIRIES ................................................................................................. 4-13 4.8 PROVINCE/TERRITORY CODES ............................................................. 4-14 4.9 ERROR CODES ........................................................................................ 4-15 4.10 ERROR REPORT MESSAGES ................................................................. 4-22 4.11 EXPLANATORY CODES ........................................................................... 4-23 4.12 SPECIALTY CODES .................................................................................. 4-29 Physician .................................................................................................... 4-29 Dental ......................................................................................................... 4-30 Practitioner ................................................................................................. 4-30 Other .......................................................................................................... 4-30 4.13 DIAGNOSTIC CODES ............................................................................... 4-32 4.14 QUESTIONS AND ANSWERS .................................................................. 4-92 February 2014 4-2 Version 1.0 Claims Submission 4. CLAIMS SUBMISSION 4.1 Overview Resource Manual for Physicians This section provides an overview of the claims submission process, including: • • • • • • 4.2 method of submitting claims process to submit claims submission of claims reports reconciliation and payment inquiries Method of Submitting Claims All claims must be submitted through electronic data transfer (EDT) in accordance with Regulation 552, Section 38.3 of the Health Insurance Act (HIA). The ministry offers two EDT services: the web-enabled Medical Claims Electronic Data Transfer (MC EDT) and the Electronic Data Transfer (EDT). Medical Claims Electronic Data Transfer The MC EDT is a secure web-enabled service that offers a: • simple user interface (web page) with basic upload and download functions using an internet connection; and • a web service for complete automation and integration with Electronic Medical Record (EMR)/Clinic Management System (CMS) software or billing software systems. The web page was implemented in October 2012 and the web service will be available in early 2013. The web page is not intended for use with automated programs or scripts. The MC EDT web page is suitable for those with a low number of daily file uploads. File uploads and downloads are a manual process and cannot be scripted or integrated with a systems interface. Users of the web service will require third party software/vendor to develop a fully automated system to submit and receive files. The MC EDT technical specifications for the web service is located on the ministry website at: http://www.health.gov.on.ca/english/providers/pub/pub_menus/pub_ohip.html February 2014 4-3 Version 1.0 Claims Submission Resource Manual for Physicians Some of the key benefits of the MC EDT service include: • • • Secure user authentication; Ability to designate access to administrative staff, third party agents or other health care providers, to act on your behalf for the submission and/or reconciliation of claim files; Additional electronic reports. The MC EDT service is available 24 hours a day, seven days a week with the exception of weekly scheduled system maintenance on Sunday mornings between the hours of 1:00 am and 5:00 am and Wednesday mornings between the hours of 5:00 am to 8:00 am. The MC EDT service currently supports the following file types: • • • Medical Claims Stale Dated Claims Overnight Batch Eligibility Checking (OBEC) For further information on MC EDT, refer to the MC EDT Reference Manual located at: http://www.health.gov.on.ca/english/providers/pub/pub_menus/pub_ohip.html Electronic Data Transfer (EDT) The EDT service is a vehicle for the electronic transmission of files from an authorized EDT user’s mailbox to the ministry’s mainframe computer via the Government of Ontario Network (GONet). The EDT service will only be available until early 2014 at which time it will be phased out. A computer with telecommunication software is required to access the EDT service and billing software is also required. Telecommunication service and associated costs/terms are the responsibility of each EDT user. You should contact a software vendor as there are specific technical requirements for the EDT service. Before you begin submitting claims, you must: • complete the “Application for GONet Electronic Data Transfer (EDT) Service” form (3274-84) and the “EDT Undertaking and Acknowledgement” form (327984). These forms are available online at: http://www.health.gov.on.ca/en/pro/forms/ohip_fm.aspx • send the completed forms to the ministry at EDT Registration, P.O. Box 68, Kingston, ON K7L 5K1 The ministry will send you an EDT User ID and temporary password when your forms have been processed. February 2014 4-4 Version 1.0 Claims Submission Resource Manual for Physicians The EDT Reference Manual has been prepared to assist you with registering for EDT. It contains the following information: • • • • • • Benefits of EDT Claims processing and payment scheduling How to register for EDT List and explanation of technical requirements Questions to ask your software vendor Glossary of terminology The EDT Reference Manual and further information on the EDT service is located on the ministry website at: http://www.health.gov.on.ca/english/providers/pub/ohip/edtguide/edt_mn.html 4.3 Process to Submit Claims Claim files must be submitted in a specific file format as outlined in the Technical Specifications-Interface to Health Care Systems manual. You should contact a software vendor to determine the most appropriate hardware and billing software that would meet your needs based on your business practices and technical capabilities. All hardware and software must conform to the specifications as contained in the Technical Specifications-Interface to Health Care Systems manual. 4.4 Submission of Claims There are three types of claims a physician will submit: • • • Health (HCP) Workplace Safety Insurance Board (WCB) Reciprocal Medical Billing (RMB) HCP Claim Health claims are claims for services rendered by physicians or private medical labs to a patient with Ontario health insurance coverage. • • • Payment program “HCP” Payee - “P” for pay provider Payee - “S” for pay patient Note: Payee is dependent on whether you opted in or opted out when you registered. February 2014 4-5 Version 1.0 Claims Submission Resource Manual for Physicians WSIB Claim Workplace Safety and Insurance Board (WSIB) (formerly Workers’ Compensation Board (WCB)) claims are for services rendered to patients with Ontario health insurance coverage who have work related injuries. • • • • • Payment program is WCB Payee is “P” for pay provider If the patient is assessed for a non-WSIB related problem during a WSIB visit (minor assessment only), A008A (Mini Assessment) may be payable. Refer to the Schedule of Benefits, sections General Preamble and Consultations and Visits A008A cannot be billed on the same claim as the WSIB service. It must be billed on a separate HCP claim. A008A can be billed only when the WSIB claim is for A001A If the physician bills any service on a WSIB claim other than a minor or partial assessment, no other assessment can be submitted as an HCP claim. Note: Other than the payment program, the information required to bill is the same as for HCP claims. The following services are excluded from WSIB submissions to the ministry: • • • • • • • • Service codes prefixed by “T” or “V” Lab services provided by private medical laboratory facilities Services provided by hospital diagnostic departments Services rendered to patients registered in other Canadian provincial plans Services rendered by out-of-province physicians Fee schedule codes: A008, K018, K021, K051, K053, K061, P004, P006 Charges for completion of form, such as M640 (must be billed directly to WSIB) Services provided by OPTED-OUT health care providers RMB Claim Reciprocal Medical Billing claims are used to bill for services rendered by physicians or private medical labs to a patient insured under another Canadian provincial health coverage plan, excluding Quebec. • • Payment program - RMB Payee - P for pay provider Note: Except for the section on patient information all other areas are identical to those on the regular HCP claim. February 2014 4-6 Version 1.0 Claims Submission Resource Manual for Physicians Patient Information Province Two letter code representing the province of the patient’s registration Registration Number Assigned to the patient in his or her province of residence (may be up to 12 characters without any spaces or special characters) Date of Birth YYYYMMDD format (e.g., 19491225) Patient’s Surname Up to 13 characters of the patient’s last name Payment Program Must be RMB Payee Must be P for pay provider Patient’s First Name Up to six characters of the patient’s first name Sex 1 (male) or 2 (female) Participation in the Reciprocal Medical Billing System (RMBS) is voluntary. Physicians who do not submit through the RMBS and bill the ministry directly must complete and submit the standard “Out of Province Claim for Physician Services” form (0000-80) available online at: http://www.health.gov.on.ca/en/pro/forms/ohip_fm.aspx Form is also used for claims for residents of Quebec and for RMB excluded services that are OHIP benefits. The following services are excluded from RMB (but are not necessarily OHIP benefits) and should be billed directly to the non-resident patient: • • • • • • • • • Surgery for alteration of appearance (cosmetic surgery) Sex reassignment surgery Surgery for reversal of sterilization Therapeutic abortion Routine periodic health examinations including routine eye examinations In-vitro fertilization, artificial insemination Lithotripsy for gall bladder stones Treatment of port wine stains on other than the face or neck, regardless of the mode of treatment Acupuncture, acupressure, transcutaneous electro-nerve stimulation (TENS), moxibustion, biofeedback, hypnotherapy February 2014 4-7 Version 1.0 Claims Submission • • • • • • • Resource Manual for Physicians Services to persons covered by other agencies (i.e., RCMP, Armed Forces, Workplace Safety and Insurance Board, Department of Veterans’ Affairs, Correctional Services of Canada [Federal penitentiaries]) Services requested by a third party Team conference(s) Genetic screening and other genetic investigation, including DNA probes Procedures still in the experimental/developmental phase Anaesthetic services and surgical assistant services associated with all of the above Services required by the Ministry of Community and Social Services and the Ministry of Attorney General or the Solicitor General Note: The patient may be eligible for direct reimbursement by his or her own provincial plan. Coding Requirements Fee Schedule Codes are located in the ministry Schedule of Benefits for Physician Services. In addition, the following information will assist with the submission of claims: • • Diagnostic Codes Services Requiring Diagnostic Codes Cut-Off Date for Claims Submission The ministry operates on a monthly billing cycle. Claims received by the 18th of the month will typically be processed for payment by the 15th of the following month. When the 18th falls on a weekend or holiday, the deadline will be extended to the next business day. Claims received after the 18th of the month will be processed prior to month end if time and volumes permit. Claims must contain complete, valid and accurate information in order to be processed on time. Claims requiring internal review by ministry staff may have payment delayed. The ministry recommends daily or weekly submissions of claims to ensure timely adjudication of claims files and to aid in the subsequent reconciliation of rejected claims. February 2014 4-8 Version 1.0 Claims Submission Resource Manual for Physicians Resubmission of Unpaid Claims In accordance with regulation under the HIA, all claims must be submitted within six months of the date of service. This includes original claims, resubmitted claims and Remittance Advice (RA) payment inquiries. Claims submitted more than six months following the date of service are termed “stale dated” claims. Claims Requiring Documentation The manual review indicator is a field in your medical claims billing software which allows you to inform the ministry that special attention is required to process a specific claim. Supporting documentation should be faxed to your claims processing office when the claim is submitted: http://www.health.gov.on.ca/en/pro/programs/ohip/claimsoffice/default.aspx Supporting documentation may include an operative report, or a “Claims Flagged for Manual Review” form (2404-84). The reasons for submitting this form as supporting documentation are listed on the form. A “Request for Approval of Payment for Proposed Surgery” form (0691-84) is another supporting document; however, it is to be submitted to your claims processing office prior to the service being rendered. These forms are available at http://www.health.gov.on.ca/en/pro/forms/ohip_fm.aspx 4.5 Reports The following reports are sent electronically from the ministry. Only reports applicable to your practice will be sent to you. All reports must be retrieved (downloaded) for review or appropriate action. File Reject Message A File Reject Message notifies you if the ministry has rejected an entire claims file. This report is usually sent within a few hours of the ministry receiving your claims submission. Batch Edit Report A Batch Edit Report notifies you of the acceptance or rejection of claims batches. This report is usually sent within 24 hours of the ministry receiving your claims submission. If claims are uploaded on a weekend, holiday or at month end, the Batch Edit Report is delivered on the next claims processing day. February 2014 4-9 Version 1.0 Claims Submission Resource Manual for Physicians Claims Error Report Claims submitted may be rejected for a variety of error conditions. Each file submission processed by the ministry will generate an Error Report (if applicable), therefore, several error reports may be received throughout the month based on the frequency of claims submissions. Claims rejected to an Error Report are automatically deleted from the payment stream. Rejected claims must be corrected and resubmitted to be processed for payment. A Claims Error Report provides a list of rejected claims and the appropriate error codes or error report message for each claim. Error codes may be reported at the header level of a claim and/or at the item level. Rejected claims may have more than one error code or error report message assigned (refer to section – Error Codes or Error Report Messages for further detailed explanation of the possible error codes). The Error Code is a three-character alpha/numeric code. The first character is an alpha and denotes the type of reject as follows: V A E R Validity Error (applies to HCP/WCB/RMB payment programs) Assessment Error (applies to HCP/WCB/RMB payment programs) Eligibility Error (applies to HCP/WCB/RMB payment programs) Reciprocal Medical Billing (RMB) Specific Errors A rejected claims item may be internally re-routed to the Error Report by the ministry and will include an error report message. The error report message is generated to provide more detailed information as to why the claim is being returned. Error report messages appear directly below the related claim item (refer to section – Error Report Messages). Rejected claims shown on the Error Reports are returned during the processing month. The corrected information should be resubmitted immediately. If the resubmitted information is received prior to the 18th of the same month, the claim can be processed for payment in the same billing cycle. Claims must be resubmitted within six months of the date of service to avoid being rejected as a stale dated claim. Claims Error Reports should be retained on file in your office to assist in monthly payment reconciliations. If claims are not approved for payment on your monthly Remittance Advice Report (RA), then check your Error Report for that month to determine if the claim was rejected and needs to be submitted again. A Claims Error Report is usually sent within 48 hours of claims file submission. If claims are uploaded on a weekend, holiday or at month end, the Error Report is delivered on the next claims processing day. February 2014 4 - 10 Version 1.0 Claims Submission Resource Manual for Physicians Split Claims Error Report The Split Error Report is only available to physicians affiliated with a primary care group. This report summarizes an individual physician’s rejected claims that were submitted under the group number. A list of rejected claims and the appropriate error codes for each claim will appear on the report (refer to section – Error Codes). Remittance Advice Report (RA) An RA is a monthly statement of approved claims. You will receive your RA between the 5th and 7th of the month following the successful submission and processing of your claims. Your RA is issued before you receive your payment on the 15th business day of each month. Group RA Split/Extract The group RA Split/Extract is only available to individual physicians within a Family Health Network (FHN) for reconciliation of their own claims. The FHN primary care groups operate over a wide area of separate physical locations and every physician in a FHN may have a different billing package and submit claims from individual locations. The RA Split/Extract contains a FHN physician’s own claim details only. OBEC Response File OBEC is a Health Card Validation (HCV) method that enables health care professionals to verify the eligibility of a patient’s health number/version code before a health service is provided. A formatted file of health numbers/version codes can be sent to the ministry for processing and eligibility is verified against the ministry’s database based on the date the file is submitted. OBEC files received by the ministry by 4:00 pm are processed overnight and the response file will be sent to your MC EDT account by 7:00 am the following morning. February 2014 4 - 11 Version 1.0 Claims Submission Resource Manual for Physicians Governance Reports Governance Reports are only sent to groups that provide specialty services in a hospital or an academic health sciences centre within specific communities. The following reports are generated monthly and sent to the MC EDT account for the governance at time of registration with the ministry. • • Academic Health Science Centre (AHSC) Governance Reports Northern Specialist Alternate Payment Program Governance Reports Primary Care Reports The following enrolment/consent reports are only sent to primary care physicians. Enrolment/Consent Outside Use Report Outside Use is a core service that is provided to enrolled patients by any family physician who is not affiliated with the patient’s primary care group. The report includes outside use details for each physician within a specific primary care group to assist in the calculation of their Access Bonus payment. Enrolment/Consent Patient Summary Report This report is a summary of patient enrolment activity to date. The report includes total number of members, breaks down total numbers into member status (e.g. assigned, enrolled, pre-members) and unconfirmed total. 4.6 Reconciliation and Payment Your RA may contain codes that indicate when a service has been reduced or disallowed because of medical rules which control the payment of claims (refer to section – Explanatory Codes). Inquiries on your RA should be submitted within one month and no later than six months from the date of service. Information updates will be transmitted via the message facility of the monthly RA. It is important that your reconciliation software allows you to read information displayed in the RA message facility. Please read all communications to ensure you are up-to-date on topics relevant to your practice. Copies of communications should be kept for reference. February 2014 4 - 12 Version 1.0 Claims Submission 4.7 Resource Manual for Physicians Inquiries Inquiries regarding overpayments or underpayments should be made within one month of the RA on which the payment appears and must be made and resolved within six months from the service date for any adjustment to payments to occur. Inquiries should be submitted to your claims processing office on a “Remittance Advice Inquiry” form (0918-84) which is available online at: http://www.health.gov.on.ca/en/pro/forms/ohip_fm.aspx February 2014 4 - 13 Version 1.0 Claims Submission 4.8 Resource Manual for Physicians Province/Territory Codes PROVINCE/TERRITORY PROVINCE CODE FORMAT ALBERTA • Prior to June 1/94, 11 numerics AB 9 numerics - individual registration (effective June 1/94) BRITISH COLUMBIA BC 10 numerics - individual registration (effective Jan. 1/91) MANITOBA • Prior to Apr 1/05, 6 numerics MB 9 numerics – individual registration (effective Apr. 1/05) NEWFOUNDLAND/LABRADOR NL 12 numerics - individual registration NEW BRUNSWICK NB 9 numerics - individual registration NORTHWEST TERRITORIES NT NOVA SCOTIA • Prior to Jan. 1/94, 11 numerics (Family Based) NS 8 characters - individual registration One alpha (N, D, M or T and 7 numerics) 10 numerics - individual registration (effective Jan. 1/94) PRINCE EDWARD ISLAND PE 9 numerics (SIN) - individual registration SASKATCHEWAN SK 9 numerics - individual registration (effective April 1/91) TERRITORY OF NUNAVUT NU 9 numerics - individual registration (effective April 1/99) YUKON YT 9 numerics - individual registration February 2014 4 - 14 Version 1.0 Claims Submission 4.9 Resource Manual for Physicians Error Codes A2A A2B A3E A3F A3L A34 A4D AC1 AC4 AD9 AH5 AH8 AMR EF1 EF2 EF3 EF4 EF5 EF7 EF8 EF9 EH1 EH2 EH4 EH5 Patient is underage or overage for this service code This service is not normally performed for this sex. Please check your records. No such service code for date of service No fee exists for this service code on this date of service Other New Pt Fee Already Pd Multiple duplicate claims Invalid specialty for this service code Maximum reached – resubmit alternate fsc A valid referring/requisitioning health care provider number must be present for this service code. Referring number is 722900-744292 (Nurse Practitioner) and FSC are not any of the following: - Laboratory Services (L***) - Cardiology codes G310, G313, G700 - Physiotherapy Code - Xray - X codes - Ultra Sound Codes - J codes Premium not allowed alone Admit date mismatch Hospital and/or Admission date is missing or invalid. - Invalid Adm Dte/Hosp No Minimum service requirements have not been met. IHF number not approved for billing on the date specified IHF not licensed or grandfathered to bill FSC on the date specified Insured services are excluded from IHF billings Provider is not approved to bill IHF fee on date specified IHF practitioner 991000 is not allowed to bill insured services Referring physician number is required for the IHF fee billed ‘I’ service codes are exclusive to IHFs Mobile site number required Srv. Date <Elig. Eff. Date Mismatched Version Code Srv. Date > Elig. End Date Srv. Dt. Not in Elig. Period February 2014 4 - 15 Version 1.0 Claims Submission ENP EPA EPC EPF EPP EPS EP1 EP2 EP3 EP4 EP5 EQ1 EQ2 EQ3 Resource Manual for Physicians Invalid FSC for NP Network billing not approved Patient not rostered/rostered to another Network Enrlmt Date Mismatch Incorrect Code for Eligibility (Ontario Works/Ontario Disability Support Program) Patient Not Elig for Prog Enrlmt Trans Not Allowed Not for Enrol/Re Enrol Check Srv Dte / Enrol Dte Enrolmnt Restriction Incorrect FSC for Grp Typ Practitioner not registered with OHIP - Clinic/Dr Not on File Specialty code is inactive or not registered on date of service Health care provider is registered as OPTED-IN for date of service – claim submitted as Pay Patient EQ4 Health care provider is registered as OPTED-OUT for date of service – claim submitted as Pay Provider EQ5 EQ6 Lab inactive for service date Referring/requisitioning health care provider number is not registered with the Ministry of Health EQ9 EQB Lab No. not on File Solo health care provider number is not actively registered with the Ministry of Health on this date of service EQC EQD Practitioner number is Midwife (700000 - 722899) referral only Claims submitted by Chiropractors using their CSN Group number is not registered with the Ministry of Health. Group number is not actively registered with the Ministry of Health on this date of service EQE Health care provider is not registered with the Ministry of Health as an affiliate of this group on date of service EQF Health care provider is not actively registered with the Ministry of Health as an affiliate of this group on date of service EQG EQJ Referring laboratory is not registered with the Ministry of Health New Graduate bills New Patient fee (q013) or Physician (not a new graduate) bills new Graduate – New Patient fee (Q033) - Pract. Not Elig. On S/D A100 billed with a specialty code other than 00. - MNI Does not Meet Criteria EQK February 2014 4 - 16 Version 1.0 Claims Submission Resource Manual for Physicians EQL A100 billed with a speciality code other than 00 or billed by provider with any EDAFA group number. - Phy Not Eligible to Claim EQM EQN EQS ERF ESD ESF Not Registered for Use Reg Usage Err on S/D Provider does not have a sub-specialty of PSY. - Pract Criteria Not Met Referring physician number is currently ineligible for referrals APP group affiliation on service date A non-encounter service claim submitted by a physician not eligible to bill FSC If a claim is submitted by a Mental Health Sessional Group for a code other than K400A, reject the claim to the error report. - Not Elig. For Blank HN ESH ESN If health number is on the claim for K400A- No HN required for FSC. Invalid Blank HN Claim ET1 The telemedicine billing is submitted by a physician who is not registered as a Telemedicine physician. - Not Reg for Telemedicine ET4 The telemedicine billing does not include a telemedicine premium code (B100, B101, B102, B200, B201, B202) - Telemed Fee code missing ET5 The telemedicine billing is submitted with a telemedicine premium/tracking code but the SLI code is not ‘OTN’ or is not present. - Telemed SLI Missing/Invld Not on Health Care Connect (HCC) database - Not Eligible On HCC database but not Complex-Vulnerable On HCC database but not in 'referred to' status Patient enrolled to billing physician but later than 3 months from the “referred to” date on Health Care Connect database - Enrolment after 3 Months HCC HCE PAA To ensure the smoking cessation initial discussion fee (E079) has been paid within 365 days prior to the smoking cessation counseling fee (Q042) or the smoking cessation follow up fee (K039) - No Initial Fee Prev. Pd. PA1 Physician Assistant (PA) Pilot claim submissions may contain one or more PA Tracking FSC’s but other OHIP insured service FSCs are not allowed on the same claim. - Invalid PA Srv PA2 Physician Assistant Pilot (PA) claim submissions with the PA as the submitting physician must identify the solo billing number of the supervising physician in the “Refer Physician” field. - Invalid PA Claim PA3 The physician and/or referring physician fields on the PA Pilot claim submission contain billing numbers which are not affiliated to the PA Pilot group number. Not registered for PA PA4 PA5 PA Registrn on S/D Err PA Affiliation Error February 2014 4 - 17 Version 1.0 Claims Submission Resource Manual for Physicians PA6 R01 R02 PA Affil’n on S/D Err Missing HSN Invalid HSN R03 R04 R05 R06 R07 R08 Invalid/Missing Province Code Service Excluded from RMBS Provincial code is 'ON' (Ontario) which is not valid for RMBS Wrong Provider for RMBS Invalid Pay Type for RMBS Invalid Referral Number TM1 TM2 TM3 TM4 TM5 TM6 TM7 TM8 V02 V05 V06 V07 V08 Dup Telemed Claim, Same patient (uninsured) Can’t Bill with MSD/CNC AP Service not Telemedicine Payable Non Telemed Claim paid for same patient Telemed Claim Paid for same patient Registration not in effect on Service Date Dental Service not eligible for Telemedicine Not eligible for Store FD Invalid Region Code Error - Clm No/Serv Date Incorrect Clinic Code Invalid Pract. Number Invalid Specialty Code Specialty code is missing/not 2 numerics Not a valid specialty code Specialty code is 27 and provider number is not 599993 Specialty code is 90 and provider number is not 991000 Specialty code is 49, 50, 51, 52, 53, 54, 55, 70 and 71 and the health care provider number does not begin with 4 Specialty code is 56 and health care provider number does not begin with 80 or 81 Specialty code is 57 and health care provider number does not begin with 86 or 839985 Specialty code is 58 and health care provider number does not begin with 87 Specialty code is 59 and health care provider number does not begin with 88 or 89 or not in range 830000 – 839984 February 2014 4 - 18 Version 1.0 Claims Submission Resource Manual for Physicians Specialty code is 80 or 81 and health care provider number does not begin with 82 V09 V10 V12 V13 V14 V16 V17 V18 V20 Invalid Referral Number Patient’s last name is missing/not alphabetic (A - Z) First field position is blank RMB claim only Patient’s first name is missing/not alphabetic (A - Z) First field position is blank RMB claim only Patient’s date of birth is missing/invalid format Month not in the range of 01 – 12 Not 8 numerics (new MRI format) Day is outside acceptable range for month Patient sex must be ‘1’ (male) or ‘2’ (female) RMB claim only Unacceptable Diagnostic Code Not numeric Health care provider number is 82XXXX and diagnostic code is not 4 numerics or is 3 numerics and not 070, 072, 880 or 971 Fee schedule code is G423, G424 and diagnostic code is not 360, 371 or 376 Payee must be ‘P’ (Provider) or ‘S’ (Patient) In-patient admission date is not 8 numerics Month of admission is not in the range of 01 - 12 Day of admission is outside the acceptable range for month In-patient admission date is later than Ministry of Health system run date Service code is A007, patient is over 2 years old and diagnostic code is ‘916’ or service code is A003 and the patient is under 16 years old and the diagnostic code is ‘917’ V21 V22 V23 V28 V29 V30 V31 Diagnostic Code Required Invalid Diagnostic Code Check No. Of Services Invalid Hospital Number Invalid In-Out-Pat-Ind FSC/DX Code Combination NAB Missing any of the following: group number, health care provider number, specialty code V34 Service code begins with ‘V1’ and health care provider number does not begin with 88 or 89, or in range 830000 - 839984 (and the reverse of this February 2014 4 - 19 Version 1.0 Claims Submission Resource Manual for Physicians condition) Service code begins with ‘V2’ and health care provider number does not begin with 86 or is 839985 (and the reverse of this condition) Service code begins with ‘V3’ and health care provider number does not begin with 87 (and the reverse of this condition) Service code begins with ‘V4’ and health care provider number does not begin with 80, 81, 84 or 85 (and the reverse of this condition) Service code begins with ‘V8’ and health care provider number does not begin with 82 (and the reverse of this condition) Service code begins with ‘T’ and health care provider number does not begin with 4, excluding fee schedule codes J99-- (and the reverse of this condition) Service code begins with ‘H4’ and health number is not a sessional reference number V35 V36 V39 V40 V41 V42 V47 V50 V51 V53 V62 V63 Invalid OOP/OOC Service Check input criteria required for sessional billing Number of items exceeds the maximum (99) Service code is missing Service code is not in the format ANNNA where: A is alphabetic (A - Z) NNN is numeric (001 - 999) A is alphabetic (A - C) Fee submitted is missing/not 6 numerics Fee submitted is not in the range ‘000000’ - ‘500000’ ($$$$cc) Number of services is missing/not 2 numerics Number of services is not in the range ‘01 - 99’ Fee submitted is not evenly divisible (to the cent) by the number of services Service Date Pre Initial Visit Invalid location code - must be blank or four numerics. If present, must be valid based on MOHLTC Residency Code Manual Invalid FSC-Magnetic Tape/Disk Invalid service location indicator – assigned when a Service Location Indicator (SLI) code included with a hospital diagnostic service billing from a participating hospital physician/group is not of the five valid SLI codes (HDS, HED, HIP, HOP or HRP) Referring Laboratory Number must start with 5 (5###) February 2014 4 - 20 Version 1.0 Claims Submission Resource Manual for Physicians V64 Missing service location indicator – assigned when a hospital diagnostic service is billed by a participating hospital physician/group but a service location indicator code was not included V65 Missing master number – assigned when SLI code HDS, HED, HIP, HOP or HRP is included with a diagnostic service billing from a participating hospital physician/group but a master number was not included V66 Missing admission date – assigned when SLI code HIP is included with a diagnostic service billing from a participating hospital physician/group but an admission date was not included V67 Missing master number and admission date – assigned when a SLI code HIP is included with a diagnostic service billing from a participating hospital/group but a master number and admission date were both not included V68 Incorrect service location indicator – assigned when a diagnostic service is billed from a participating hospital physician/group with a master number and admission date but the SLI code is not HIP V69 V70 V71 VHB VH1 VH2 VH3 VH4 VH8 VH9 VJ5 Serv Dte Invalid for SLI Date of service is greater than the file/batch creation date Invalid Dental Master No. No HN Req’d for FSC Health Number is Invalid HN is Missing Invalid Payment Program Invalid Version Code No Match on DOB with HN HN Not Reg’d with MOH Date of Service is missing/not 8 numerics Month is not in the range 01 - 12 Day is outside acceptable range for month Date of Service is greater than Ministry of Health system run date Stale-dated Claim Invalid SEAMO Prvdr Code Invalid Venue Type Invalid Clinic Number Invalid Healthcare Item Invalid IP/OP Indicator Invalid HC Item Cde Fmt Invalid WCB Service VJ7 VS1 VS2 VS3 VS4 VS5 VS6 VW1 February 2014 4 - 21 Version 1.0 Claims Submission Resource Manual for Physicians 4.10 Error Report Messages 02 03 04 05 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Incorrect District code 0 Correct & resubmit Date of service does not match OP report - correct & resubmit Special Visit premium payable only when submitting with FSC from the general listings No receipt of supporting documentation requested by MOH Fee Schedule Code(s) used is not correct. Please resubmit using appropriate code(s) from OHIP Schedule of Benefits Resubmit as RMB Claim Bill Patient or Quebec Medicare Please advise Patient to contact MOH re eligibility /card status/address Service date is prior to newborn’s date of birth Fee billed low – check for current SOB fee No. of Services exceed Maximum allowed Cannot be claimed alone/service date mismatch E409/E410 N/A – Resubmit with appropriate assist/anaesthetic premium codes Resubmit with man review indicator and provide supporting documentation for two assistants Resubmit with manual review indicator and forward copy of OP Report Resubmit with manual review documentation i.e. consultation report/Hospital Records Records indicate patient deceased/ Please clarify or confirm. Code submitted requires prior approval Hospital visits claimed by more than one physician – please clarify role in patient’s care Claims appearing on previous RA’s as Over/Under Payments should not be resubmitted; please use inquiry form for payment adjustment requests. Incomplete newborn registration – have parent/guardian contact MOH One house call assessment (A901) allowed per visit. Please resubmit claim with appropriate service code This duplication submission is being returned; Original submission currently on file pending medical consultant adjudication Resubmit with manual review indicator with written explanation for detention. Total time spent with patient including consultation/assessment indicated. Discrepancy between claim and documentation. Resubmit claim and documentation. February 2014 4 - 22 Version 1.0 Claims Submission Resource Manual for Physicians 4.11 Explanatory Codes 30 31 32 35 Service is not a benefit of OHIP Not a valid network service OHIP records show service(s) on this day claimed previously 36 OHIP records show service has been rendered by another Practitioner, Group, Lab Effective April 1, 1993 the listed benefit for this code is 0 LMS units Service or related service allowed only once for same patient Specialty code restriction on FSC 37 40 45 48 OHIP records show this service rendered has been claimed previously (used on Pay Practitioner duplicate claims) Paid as submitted - clinical records may be requested for verification purposes 49 50 51 52 53 54 55 56 57 58 59 60 62 66 70 80 C1 C2 C3 Paid according to the average fee for this service. Independent consideration will be given if clinical records/operative reports presented. Paid in accordance with the Schedule of Benefits Fee Schedule Code changed in accordance with Schedule of Benefits Fee-for-service assessed by medical consultant Fee allowed according to appropriate item in a previous Schedule of Benefits Interim payment - claim under review Deduction is an adjustment on an earlier account Claim under review This payment is an adjustment on an earlier account Claimed by another physician within group Practitioner’s notification - WCB claims Not a benefit of the Reciprocal Medical Billing Agreement Claim assessed by Assessment Officer Reduced per APP Funding Contract OHIP records show corresponding procedure(s) on this day claimed previously by another physician Technical fee adjustment for hospitals Allowed as repeat/limited consultation/midwife-requested emergency assessment Allowed at re-assessment fee Allowed at minor assessment fee February 2014 4 - 23 Version 1.0 Claims Submission Resource Manual for Physicians C4 C5 C6 C7 Consultation not allowed with this service - paid as assessment Allowed as multiple systems assessment Allowed as Type 2 admission assessment An admission assessment (C003A) or general re-assessment (C004A) may not be claimed by any physician within 30 days following a pre-dental/preoperative assessment C8 Payment reduced to geriatric consultation fee – maximum number of comprehensive geriatric consultations has been reached C9 Allowed as in-patient interim admission orders – initial assessment already claimed by other physician D1 D2 D3 D4 D5 D6 D7 D8 D9 DA DB DC Allowed as repeat procedure - initial procedure previously claimed Additional procedures allowed at 50% Not allowed in addition to visit fee Procedure allowed at 50% with visit Procedure already allowed - visit fee adjusted Limit of payment for this procedure reached Not allowed in addition to other procedure Allowed with specific procedures only Not allowed to a hospital department Maximum for this procedure reached - paid as repeat/chronic procedure Other dialysis procedure already paid Procedure paid previously not allowed in addition to this procedure – fee adjusted to pay the difference DD DE DG Not allowed as diagnostic code is unrelated to original eye exam Lab tests already paid - visit fee adjusted Diagnostic/Miscellaneous services for hospital patients are not payable on a fee-for-service basis in the Hospital Global budget. DH DL DM Ventilatory support allowed with Haemodialysis Allowed as laboratory tests in private office DM Paid/disallowed in accordance with MOH policy regarding an Emergency Department Equivalent Paid/disallowed in accordance with MOH policy regarding an emergency department equivalent DN Allowed as pudenal block in addition to procedure - as per stated OHIP policy DP Procedure paid previously allowed at 50% in addition to this procedure - fee adjusted to pay the difference February 2014 4 - 24 Version 1.0 Claims Submission Resource Manual for Physicians DS DT DV DX E1 E2 E4 E5 EA Not allowed – mutually exclusive code billed In-patient technical fee not allowed Service is included in Monthly Management Fee for LTC patients Diagnostic code not eligible with FSC Service date prior to start of eligibility Incorrect version code for service date Service date after the eligibility termination date Service date not within an eligible period Service date is not within an eligible period - services provided on or after the 20th of this month will not be paid unless eligibility status changes EB EF Coding added/changed in accordance with Schedule of Benefits Incorrect version code - services provided on or after the 20th of this month will not be paid unless the current version code is provided EV F1 F2 F3 F5 F6 FF G1 GF H1 H2 H3 H4 H5 H6 H7 H8 H9 HA Check health card for current version code Additional fractures/dislocations allowed at 85% Allowed in accordance with transferred care Previous attempted reductions (open or closed) allowed at 85% Two weeks aftercare included in fracture fee Allowed as Minor/Partial Assessment Additional payment for the claim shown Other critical/comprehensive care already paid Coverage lapsed - bill patient for future claims Admission assessment or ER assessment already paid Allowed as subsequent visit - initial visit previously claimed Maximum fee allowed per week after 5th week Maximum fee allowed per week after 6th week to pediatricians Maximum fee allowed per month after the 13th week Allowed as supportive or concurrent care Allowed as chronic care Hospital number and/or admission date required for in-hospital service Concurrent care already claimed by another doctor Admission assessment claimed by another physician - hospital visit fee applied HF HM I2 I3 Concurrent or supportive care already claimed in period Invalid master number used on date of service Service is globally funded FSC is not on the IHF licence profile for the date specified February 2014 4 - 25 Version 1.0 Claims Submission Resource Manual for Physicians I4 Records show service has been rendered by another Practitioner, Group or IHF I5 I6 I7 I8 I9 J3 J7 L1 L2 L3 L4 L5 L6 Service is globally funded and FSC is not on IHF licence profile L7 L8 L9 Not allowed - referred specimen Not to be claimed with prenatal/fetal assessment Laboratory services for hospital in-patients or out-patients are not payable on a fee-for-service basis - included in the hospital global budget LA LS M1 Lab service is funded by special Lab Agreement Paid in accordance to special Lab Agreement Maximum fee allowed or maximum number of service has been reached same/any provider M2 Maximum allowance for radiographic examination(s) by one or more practitioners M3 M4 Maximum fee allowed for prenatal care Maximum fee allowed for these services by one or more practitioners has been reached M5 M6 MA MC Monthly maximum has been reached Maximum fee allowed for special visit premium - additional patient seen Maximum number of sessions has been reached Maximum number of case conferences has been reached in a 12 month period MD MN MR Daily maximum has been exceeded Maximum number of occipital nerve block sessions has been reached Minimum service requirements have not been met Premium not applicable Claim date does not match patient enrolment date Confirmation not received Payment not applicable/expired Approved for stale dated processing Claim submitted six months after service date This service paid to another laboratory Not allowed to medical Laboratory Director Not allowed in addition to other laboratory procedure(s) Not allowed to attending physicians Not allowed in addition to other procedure paid to another laboratory Procedure paid previously to another laboratory, not allowed in addition this procedure - fee adjusted to pay the difference February 2014 4 - 26 Version 1.0 Claims Submission Resource Manual for Physicians MS Maximum allowed for sleep studies in a specific period by one or more physicians has been reached MX MY O1 O2 O3 O4 Maximum of 2 arthroscopy “R” codes with E595 has been reached Yearly maximum has been exceeded Fee for obstetric care apportioned Previous prenatal care already claimed Previous prenatal care already claimed by another doctor Office visits relating to pregnancy and claimed prior to delivery included in obstetric fee O5 O6 O7 O8 O9 P2 P3 P4 Not allowed in addition to delivery Medical induction/stimulation of labour allowed once per pregnancy Allowed as subsequent prenatal visit - initial prenatal visit already claimed Allowed once per pregnancy Not allowed in addition to post-natal care Maximum fee allowed for low birth weight care Maximum fee allowed for newborn care Fee for newborn care/low birth weight care is not billable with neonatal intensive care P5 P6 P8 P9 PM Q7 Q8 R1 RD S1 S2 S3 S4 S5 S6 S7 SA SB Over-age for paediatric rates of payment Over-age for well-baby care HCC GT 3 months Complex New patient Minimum roster size not met No fee allowed for treatment of immediate family Lab not licensed to perform this test on date of service Only one health exam allowed in a twelve-month period Duplicate, paid in RMBS Bilateral surgery, one stage, allowed at 85% higher than unilateral Bilateral surgery, two stage, allowed at 85% higher than unilateral Second surgical procedure allowed at 85% Procedure fee reduced when paid with related surgery or anaesthetic Not allowed in addition to major surgical fee Allowed as subsequent procedure - initial procedure previously claimed Normal pre-operative and post-operative care included in surgical fee Surgical procedure allowed at consultation fee Normal pre-operative visit included in surgical fee - visit fee previously paid surgical fee adjusted February 2014 4 - 27 Version 1.0 Claims Submission Resource Manual for Physicians SC SD SE Not allowed, major pre-operative visit already claimed Not allowed, Team/Assist Fee already claimed Major pre-operative visit previously paid and admission assessment previously paid - surgery fee reduced by the admission assessment SF Most Responsible Physician visit not allowed during post operative period – surgical fee adjusted. SV MRP visit not allowed during post operative period – fee reduced to subsequent visit fee. T1 V1 V2 V3 V4 V5 Fee allowed according to surgery claim Allowed as repeat assessment - initial assessment previously claimed Allowed as extra patient seen in the home Not allowed in addition to procedural fee Date of service was not a Saturday, Sunday or statutory holiday Only one OVA allowed within a 12-month period for age 19 and under, or 65 and over - and one within 24 months for age 20 - 64 V6 V7 V8 V9 VA VB Allowed as minor assessment - initial assessment already claimed Allowed at medical/specific re-assessment fee This service paid at lower fee as per stated OHIP policy Only one initial office visit allowed within a twelve-month period Procedure fee reduced - consultation/visit fees not allowed in addition Additional OVA is allowed once within the second year for patients aged 2064, following a periodic OVA VG Only one geriatric general assessment premium per patient per 12-month period VM Oculo-visual minor assessment is allowed within 12 consecutive months following a major eye exam VP VS VX W4 X2 X3 X4 X5 X6 Allowed with special visit only Date of service was a Saturday, Sunday or statutory holiday Complexity premium not applicable to visit fee Warning: - service location indicator code missing G.I. tract includes cine and video tape G.I. tract includes survey film of abdomen Only one BMD allowed within a 36 month period for a low risk patient Only one BMD allowed within a 12 month period for a high risk patient Only one BMD allowed within a 60 month period for a low risk patient February 2014 4 - 28 Version 1.0 Claims Submission Resource Manual for Physicians 4.12 Specialty Codes This is a list of specialties or disciplines recognized by the Royal College of Physicians and Surgeons of Canada relevant to services covered by the Ministry of Health and Long-Term Care. Code 00 Physician Family Practice and Practice in General 01 Anaesthesia 02 Dermatology 03 General Surgery 04 Neurosurgery 05 Community Medicine 06 Orthopaedic Surgery 07 Geriatrics 08 Plastic Surgery 09 Cardiovascular and Thoracic Surgery 12 Emergency Medicine 13 Internal Medicine 15 Endocrinology 16 Nephrology 17 Vascular Surgery 18 Neurology 19 Psychiatry 20 Obstetrics and Gynaecology 22 Genetics 23 Ophthalmology 24 Otolaryngolgy 26 Paediatrics 27 Non-Physician Lab Director 28 Laboratory Medicine 29 Microbiology 30 Clinical Biochemistry 31 Physical Medicine 33 Diagnostic Radiology 34 Therapeutic Radiology February 2014 4 - 29 Version 1.0 Claims Submission Resource Manual for Physicians 35 Urology 41 Gastroenterology 44 46 47 Medical Oncology Infectious Disease Respiratory Disease 48 56 Rheumatology Optometrists 58 Chiropodists 60 61 Cardiology Haematology 62 63 Clinical Immunology Nuclear Medicine 64 70 Thoracic Surgery Oral Radiology 71 Prosthodontics 85 86 Alternate Health Professionals Generic Referral 99 Code RMBS OOP/OOC 49 Dental Surgery 50 Oral Surgery 51 Orthodontics 52 Paedodontics 53 Periodontics 54 Oral Pathology 55 Endodontics Code Practitioner 56 Optometry 58 Chiropody (Podiatry) 80 Private Physiotherapy Facility (Approved to Provide Home Treatment Only) 81 Private Physiotherapy Facility (Approved to Provide Office/Home Treatment) Code Other Dental February 2014 4 - 30 Version 1.0 Claims Submission Resource Manual for Physicians 27 Non-medical Laboratory Director (Provider Number Must Be 599993) 75 Midwife (Referral Only) 76 85 Nurse Practitioner Alternate Health Care Profession 90 IHF Non-Medical Practitioner (Provider Number Must Be 991000) February 2014 4 - 31 Version 1.0 Claims Submission Resource Manual for Physicians 4.13 Diagnostic Codes Alpha Diagnosis Abdominal Abortion Abrasions Abruptio Placenta Abscess Description Pain, Masses Adhesions Advice Complete, Incomplete Missed Therapeutic Threatened Anal or Rectal Regions Bartholin's Gland Brain Breast Dental Fallopian Tube, Ovary or Tubo-ovarian Pilonidal Tissue, Other Skin and Subcutaneous Urinary System Acariasis Acne Rosacea Vulgaris Acromegaly Actinomycotic Infection Addison's Disease Adenitis Cervical Adentis - see Lymphadenitis, Acute Adenoids, Chronic Infection Adenoma Parathyroid Adjustment Reaction Adrenogenital Syndrome Adverse Effects February 2014 Code 787 560 895 634 632 635 640 919 641 566 616 349 611 525 614 682 685 590 133 706 695 706 253 039 255 289 683 474 259 309 255 Of Drugs and Medications, including allergy, overdose, reactions 4 - 32 977 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Agammaglobulinemia Aged Parent Problem Agranulocytosis A.I.D.S. A.I.D.S. (A.R.C.) Alcoholic Psychosis Alcoholism Allergy Alopecia Alveolitis, Oral Cavity Alveolitis, Lung Amblyopia Amoebiasis Amenorrhea Amino-acid - Acid Metabolism Disorder Amputation, Traumatic Anal Anaphylaxis Anemia February 2014 Description Or Other Chemicals (e.g., lead pesticides and venomous bites) Of Surgical And Medical Care (e.g., wound infection, wound disruption, other iatrogenic disease) Of Physical Factors (e.g., heat, cold, frostbite, pressure) Acquired Immune Deficiency Syndrome Acquired Immune Deficiency Syndrome Related Complex Bronchitis Drugs and Medication Rhinitis Lower Limb(s) Upper Limb(s) Fissure, Fistula Stricture Aplastic Hemolytic, acquired excluding hemolytic disease of newborn Hemoytic, Hereditary Iron Deficiency Pernicious Sickle Cell Other Anemias 4 - 33 Code 989 994 998 279 900 288 042 043 291 303 493 977 477 704 525 518 368 006 626 270 894 884 565 569 995 284 283 282 280 281 282 285 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Aneurysm, Aortic (non-syphilitic) Aneurysm, Others Angina, Ludwig's Angina Pectoris Angina, Vincent's Ankylosing Spondylitis Ankylosis, Joint Annual Health Examination Anorexia Anorexia Nervosa Anuria Anxiety Neurosis Aphakia Appendicitis, Acute Arrythmias, Cardiac, Other Arteriosclerosis Arteriosclerotic Cerebrovascular Disease, Chronic Arteriosclerotic Heart Disease (A.S.H.D.) Without Symptoms Arteritis, Temporal Arthralgia Arthritis Description Adolescent/Adult With or without abscess or peritonitis Cerebral with psychoses Generalized 447 529 413 136 720 718 917 787 307 788 300 360 540 427 298 440 437 412 Osteo Pygenic Rheumatoid Traumatic Arthrogryposis (Contracture of Joint) Asbestosis Ascites Asphyxia Asthma Astigmatism Astroblastoma February 2014 Code 441 446 781 715 711 714 716 728 501 787 799 493 367 191 4 - 34 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Astrocytoma Ataxia Atelectasis Atherosclerosis Athlete's Foot Atrial Fibrillation, Flutter Autism Automated Visual Field Baker's Cyst Basal Cell Carcinoma Battered Child Bed Sore Bee Sting Behavior Disorders of Childhood and Adolescence Bell's Palsy Bends Benign Prostatic Hypertrophy (B.P.H.) Birth Trauma Bites, Non-venomous Bites, Venomous Bleeding Blepharitis Blindness Blood Poisoning Boil Botulism Bradycardia Branchial Cyst Bronchiectasis Bronchitis Description AVF test 351 994 600 Post-menopausal Rectal Acute Allergic Chronic Brucellosis Bruises Buerger's Disease February 2014 Code 191 780 518 440 110 427 299 918 727 173 899 707 989 313 4 - 35 767 919 989 627 569 373 369 038 680 136 427 744 494 466 493 491 023 919 443 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Bullet Wound Bunion Burns Bursitis Calculus (Stone) Calluses Candidiasis Canker Sore Carbuncle Cardiac Arrest Cardiospasm Carpal Tunnel Syndrone Cartilage Tear Cataract Carcinoma In Situ Description If open wound use code for appropriate area – see Open Wounds If internal injury use Thermal or Chemical Bile Duct Bladder Kidney Lacrimal Duct Liver Prostate Salivary Glands Ureter Congenita Excluding Diabetic or Congenital Breast Digestive Organs Genito-urinary System Skin Respiratory System Other Celiac Disease Cellulitis Cephalgia Cephalo-pelvic Disproportion Cerebral Degenerations, Other Cerebral Haemorrhage Cerebral Ischaemia, Transient February 2014 Code 869 727 949 727 576 592 592 368 573 592 527 592 700 112 528 680 427 530 739 718 744 366 233 230 233 232 231 234 579 682 780 653 331 432 435 4 - 36 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Cerebral Palsy Cerbro-vascular Accident, Acute (C.V.A.) Cerrebral Thrombosis Cerumen in Ear Cervical Dysplasia Cervical Erosion Cervical Hyperplasia Cervicitis Description During Pregnancy Chalazion Chicken Pox Child Abuse, Child Neglect Childhood Psychosis Cholecystitis without Gallstones Cholelithiasis (Gallstones) Chorea Chorioretinitis Choroiditis Chronic Fatigue Syndrome Circumcision, Newborn Cirrhosis Claudication, Intermittent Claustrophobia Cleft Palate, Lip Club Foot Coagulation Defects Coarctation of Aorta Coccydynia Cold, Common Cold Sore Colic, Renal Colitis February 2014 Code 343 436 436 388 622 622 752 616 646 373 052 899 299 575 With or Without Cholecystitis 574 363 636 363 795 Liver, Alcoholic, Biliary Mucus Ulcerative 4 - 37 609 571 443 300 749 754 286 747 724 460 054 788 564 556 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Colon Colon Positive Fecal Occult Blood Colon Surveillance Colon Family History of Colon Cancer Colon Screening Compression of Umbilical Cord Concussion Conduction Disorders, Other Condyloma Condylomata Accuminata Congenital Anomalies Description Spastic, Irritable 546 547 548 762 850 426 099 079 Autosomal, Chromosomal Circulatory System Digestive System Ear, Face, Neck Eye Genital Organs Heart Limbs Musculoskeletal System Nose and Respiratory System Pylorus, Mouth, Esophagus, and Stomach Sex Chromosomes Urinary System Congestive Heart Failure Conjunctiva Disorders (e.g., Conjuntivitis) Conn's Syndrome Constipation Contraceptive Advice Contusions Convulsions Cord Prolapse Corneal Ulcer Corns February 2014 Code 564 545 4 - 38 758 747 751 744 743 752 746 755 756 748 750 758 753 428 372 255 564 895 919 780 762 370 700 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Coronary Artery Disease, Chronic, Without Symptoms Coronary Insufficiency, Acute Coronary Thrombosis Cough Coxsackie Pleurodynia Cramps of Leg Cretinism Crohn's Disease Croup Cushing's Syndrome C.V.A. Cyst Description 413 Cerebrovascular Accident Baker's Bartholin's Gland Bone Branchial Breast Dental Dermoid Hydatid All Sites Lip (mucocele) Ovarian Pilonidal Renal Sebaceous Urachal Cystic Fibrosis Cystic Disease, Chronic or Cystic Mastitis Cystinuria Cystitis During Pregnancy Cystocele Dacrocystitis Deafness, All Types Decubitus Ulcer February 2014 Code 412 4 - 39 410 786 074 781 243 555 464 255 436 727 616 213 745 610 525 228 122 210 220 685 223 706 753 277 610 270 595 634 618 375 389 707 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Deficiency Dehydration Delirium Tremens Delivery Dementia Dental Caries Depression, Reactive Depressive or Other Non-psychotic Disorder, Not Classified Elsewhere Dermatitis Dermatomyositis Detachment, Retinal Deviated Nasal Septum Diabetes Mellitus (Including Complications) Diabetes Mellitus with Ocular Complications Diabetes Insipidus Diaper Rash Diarrhea Difficulty at Work Diphtheria Diplopia Disease February 2014 Description Mental Iron Nutritional, Vitamin Normal With Other Complications With Placenta Praevia, Abruptio Placenta Senile, Presenile Allergic, Atopic Contact Neuro Seborrheic Code 319 280 269 277 291 650 669 641 290 521 300 311 691 692 691 690 710 361 470 250 248 Addison's A.I.D.S Arteriosclerotic Arteriosclerotic Heart Bacterial Buerger's Breast Cystic, Chronic 4 - 40 253 691 009 905 032 368 255 042 437 412 040 443 610 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Dislocation Diverticulitis Divorce Dizziness Down's Syndrome February 2014 Description Bright's Christmas Crohn's De Quervaine's Duchennes Graves Hansen's Hashimoto Hemolytic of Newborn Hirchsprung's Megacolon Hodgkin's Huntington's Chorea Hypertensive Heart Hypertensive Renal Ischaemic Heart Legg Perthes Lung, Other Marie Strumpell Meniere's Motor Neurone Osgood-Schlatter Paget's - of bone Parkinson's Pelvic - inflammatory, chronic (P.I.D.) Peripheral Vascular (P.V.D.) Raynaud's Respiratory System, other Still's Tay-Sachs Venereal Viral, Arthropod-borne Elbow Finger Other Recurrent Shoulder or Diverticulosis of small or large intestine 4 - 41 Code 580 286 555 727 099 242 030 245 773 751 201 349 402 403 413 732 518 720 386 349 732 731 332 614 443 519 398 714 330 099 066 832 834 839 718 831 562 901 780 758 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Drug Addiction, Dependence Drug Overdose Drug Psychosis Duodenal Ulcer, With or Without Haemorrhage or Perforation Dupuytren's Contracture Dwarfism Dysentery Dysfunction Dyslalia Dyslexia Dysmenorrhea Dyspareunia Dyspepsia Dysphagia Dysplasia, Cervical Dyspnea Dystrophy, Muscular Dysuria Echinococcosis Eclampsia Economic Problems Ectopic Pregnancy Ectropion Eczema Edema Educational Problems Embolism Description 977 292 532 Amoebic Ovarian Pituitary Gland Sexual Not yet diagnosed Post-partum pulmonary Pulmonary Emphysema Encephalitis Viral, Mosquito Borne Encephalomyelitis Encephalopathy, Hypertensive Endocarditis February 2014 Code 304 728 253 006 256 253 306 315 315 625 625 536 787 622 786 359 786 122 642 897 633 374 691 785 902 677 415 492 323 062 323 437 429 4 - 42 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Endometriosis Enteritis Enterocele Entropion Enuresis Eospinophilia Epididymitis Epiglottitis, Acute Epilepsy Epistaxis Erosion, Cervical Erysipelas Erythema, Multiforme or Nodosum Esophagitis Eustachian Tube Disorders Eye Disorders, Other Eyelid Disorders, Other Facial Nerve Disorders False Labour Family Disruption Family Planning Fanconi Sydrome Fever Description Acute or Chronic Regional Gastro Mental Disorder 530 381 Glandular Hay Rheumatic with or without Endocarditis, Myocarditis or Pericarditis Scarlet Typhoid Fibrillation Fibro-adenosis of Breast Fibrosis Cystic Pulmonary Fissure, Anal Fistula, Anal Flat Foot February 2014 Code 617 615 555 009 618 374 307 288 604 464 345 786 622 035 695 4 - 43 379 374 351 644 901 895 270 075 477 391 034 002 427 610 277 515 565 565 734 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Flutter, Atrial or Ventricular Food Poisoning Foreign Body Fractures, Fracturedislocation Frigidity Frostbite Fungus - See Mycoses Furunculosis Gallstones (Calculus) Ganglion Gastric Ulcer Gastritis Gastro-enteritis and Gastro-enteritis, Viral German Measles (Rubella) Gingivitis Glandular Fever Glaucoma Glmerulonephritis, Acute February 2014 Description Eye or other tissues Ankle Carpal Bones Clavicle Facial Bones Femur Fibula Humerus Metacarpals Pelvis Phalanges Radius Ribs Skull Spontaneous Tibia Ulna Vertebral Column with spinal cord damage Vertebral Column without spinal cord damage Other Cholelithiasis, with or without Cholecystitis Code 427 005 930 824 814 810 802 821 823 812 815 808 816 813 807 803 733 823 813 806 805 829 302 994 680 574 727 531 535 009 056 523 075 365 580 4 - 44 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Glossitis Goitre Gonococcal Infections Gout Granuloma, Pyogenic Gynecomastia Habit Spasms Haemorrhage, Eye Haemorrhage, Intracranial Haemorrhage in Early Pregnancy Haemorrhage, Post Partum Haemorrhagic Conditions, Other Haemorrhoids Halitosis Hallux Valgus or Varus Hammer Toe Hansen's Disease (Leprosy) Hay Fever Headache (Cephalgia) Description Exophthalmic Nontoxic Nodular Simple Thyroid 640 666 287 455 787 735 735 030 Migraine Tension Except tension and migraine Heart Blocks Heartburn Heart Disease, All Other Forms Heart Failure, Congestive Helminthiases Hemangioma Hematemesis Hematuria Hemiplegia February 2014 Code 529 242 241 240 098 274 686 611 307 379 432 477 346 307 780 426 787 429 428 128 228 787 599 599 4 - 45 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Hemolytic Anemia, Hereditary Hemolytic Disease of Newborn Hemophilia Hemoptysis Hepatitis Hernia Herpes Genitalis Herpes Simplex Herpes Zoster Hiccough High Birthweight Infant High Myopia Description 773 Femoral, umbilical, ventral, diaphragmatic or hiatus hernia with obstruction Femoral, umbilical, ventral, diaphragmatic or hiatus hernia without obstruction Inguinal with or without obstruction Greater than 9 diopters, irregular astigmatism resulting from post-corneal grafting or corneal scarring from disease Hirsutism Histoplasmosis Hives Hodgkin's Disease Hunner's Ulcer Hyaline Membrane Disease Hydrocele Hydrocephalus Hydronephrosis Hyperactive Child Hyperaldosteronism Hypercalcemia Hyperchlorhydria Hypercholesterolemia Hyperemesis Gravidarum Hyperkeratosis February 2014 Code 282 286 786 070 552 553 550 099 054 053 787 766 371 709 115 708 201 595 769 603 742 591 314 255 259 536 272 643 701 4 - 46 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Hyperkinetic Syndrome of Childhood Hypermenorrhea Hypermentropia Hyperopia Hyperplasia Hypertension, Essential Hypertensive Encephalopathy Hypertensive Heart Disease Hypertensive Renal Disease Hypertensive Retinopathy Hyperthyroidism Hypertrophy Hyperventilation Hypochlorhydria Hypogammaglobulinemi a Hypoglycemia Hypomenorrhea Hypotension Hypothyroidism Hysteria Ileitis, Regional Ileus, Paralytic Illegitimacy Immunity Disorders Immunization Impaction of Intestine Impetigo Imprisonment Incontinence of Urine February 2014 Description Adrenal Endometrial Code 314 626 367 367 259 621 401 437 402 403 362 Benign Prostatic (B.P.H.) Breast Tonsils, Adenoids Acquired Congential All types 4 - 47 242 600 611 575 786 536 279 259 626 447 244 243 300 555 560 903 279 896 560 684 906 788 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Indigestion Inertia, Uterine Infarction Infection Infertility Infestation Influenza Ingrown Nail Inguinal Hernia with or without Obstruction Injury In-laws Problem Insufficiency Intertrigo Intervertebral Disc Disorders Intussusception Iritis Irregular Astigmatism February 2014 Description Myocardial Acute Myocardial Old, Without Symptoms Pulmonary Actinomycotic Gonococcal Intracranial Meningococcal Monilia all sites Nipple, Post-partum, Salmonella Other Human Immunodeficiency Virus Infection Tonsils, Adenoids Chronic Trichomonas Vaginalis Tuberculous, Primary, Including Recent Positive T.B. Skin Test Conversion Upper Respiratory Wound Pinworm Tapeworm - all types Head Internal to Organ Superficial Other Acute Coronary Mitral Resulting from post corneal grafting or corneal scarring from disease 4 - 48 Code 536 661 410 412 415 098 039 298 036 112 003 044 474 131 010 460 998 628 127 123 147 703 550 854 869 919 959 900 413 394 695 722 560 364 371 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Ischaemic Heart Disease, Acute Ischamia, Transient Cerebral Itchy Condition, Other Jaundice Joint Korsakov's Psychosis Kyphosis Labyrinthitis Laceration Lactic Acidosis Laryngitis, Acute Legg-perthes Disease Leiomyoma Legal Problems Leprosy (Hansen's Disease) Leukoplakia Description 435 Ankylosis Arthrogryposis Contracture Derangement, Loose Bodies Pain Swelling, Masses Tuberculosis Other Disease of Keloid Keratitis Keratoconus Klinefelter's Syndrome Perineal Except Limbs Lower Limb(s) Upper Limb(s) Oral Mucosa Tongue Lice, Head or Body Lipoid Metabolism Disorder Lipoma Lipoprotein Disorders Lips, Diseases of February 2014 Code 413 698 787 718 728 718 718 781 781 015 739 701 370 376 758 291 737 386 664 879 894 884 259 464 732 218 906 030 528 529 132 272 214 272 528 4 - 49 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Litigation Lordosis Low Birthweight Infant Low Vision Ludwig's Angina Lumbago Lumbar Strain Lupus Erythematosus Lupus Erythematosus Disseminated Lymphadenitis Acute Lymphangioma Lymphangitis Lymphedema Lymphosarcoma Macrognathism Malabsorption Syndrome Malaria Malnutrition, Unspecified Malocclusion Malpresentation Manic Depressive Psychosis Marie-Strumpell Spondylitis Marital Difficulties Masses Mastitis Description 683 228 457 457 200 524 579 136 263 524 652 296 720 Circulatory System Respiratory System Digestive System Genito-urinary System Cystic Post-partum Mastoiditis Measles German, Rubella Melancholia, Involutional Melena February 2014 Code 906 737 765 369 529 724 724 695 710 898 785 786 787 788 610 675 383 055 056 296 787 4 - 50 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Meniere's Disease Meningioma (Benign) Meningitis Description Bacterial, Central Nervous System Due to Other Organisms Enterovirus Infectious Menigocele Meningococcal Infection Meningomyelocele Meniscus or Cartilage Tear Menopause Menorrhagia Menstruation Disorders Mental Deficiency, Retardation Mesenteric Artery Occlusion Metabolic Disorders, Other Metrorrhagia Micrognathism Migraine Mitral Insufficiency or Stenosis Mole Monilia Infection, All Sites Mononucleosis, Infectious Monoplegia Motor Neurone Disease Motor Retardation Multiple Pregnancy Multiple Sclerosis Mumps Muscle Spasms Muscular Dystrophy Muscular Rheumatism Myasthenia Gravis February 2014 Code 386 225 320 321 047 036 741 036 741 718 627 626 626 319 557 277 626 524 346 394 216 112 075 349 349 315 651 340 072 728 359 729 358 4 - 51 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Mycoses, All Types Myocarditis Myocardial Infarction Myoneural Disorders Myopia Myositis Myxedema Naevus, Pigmented Narcolepsy Nasal Polyp Nasopharyingitis, Acute Nausea Neck Sprain/Strain Neoplasm (Benign) Neoplasm (Benign) (Continued) February 2014 Description Artherosclerotic Rheumatic Coxsackie Acute Old Bladder Bone Brain Breast Cartilage Cervical Polyp Connective and other soft tissue Dermato Fibroma Digestive System, other parts Eye Genital Organs, female, other Genital Organs, male, other Hemangioma Intrathoracic Organs Kidney Leiomyoma Lip Lipoma Lymphangioma Oral Cavity Other Endocrine Glands/related structures Ovary, e.g. Ovarian Cyst Peripheral Nerves 4 - 52 Code 117 429 391 074 410 412 367 367 729 244 216 349 471 460 787 847 223 213 225 217 213 218 215 216 230 224 221 222 228 212 223 218 210 214 228 210 227 220 225 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Neoplasm (Malignant) Neoplasm (Malignant) (Continued) February 2014 Description Peritoneum Pharynx Respiratory System Seborrheic Wart Skin Spinal Cord Thyroid Ureter Uterine Fibroid Other Anus Astroblastoma, Astrocytoma Basal Cell Bladder Bone Brain Breast, Female Broad, Ligament Bronchus Cancer, Multiple Sites Carcinomatosis Cervix Connective and other soft tissue Cranial Nerves Esophagus Eye Fallopian Tube Gallbladder and Extra Hepatic Bile Ducts Genital Organs, female, other Genital Organs, male, other Gum Hodgkin's Disease Hypopharynx Kidney Large Intestine Excluding Rectum Larynx Leukemia, Lymphatic, Lymphocytic, Lymphoid Leukemia, Monocytic 4 - 53 Code 211 210 212 216 216 225 226 223 218 229 154 191 173 188 170 191 174 183 162 199 198 180 171 192 150 190 183 156 184 187 143 201 148 189 153 161 204 206 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Neoplasm (Malignant) (Continued) February 2014 Description Leukemia, myeloid including granulocytic and myelogenous Leukemia, other types Leukemia, plasma cell Lip Liver, primary malignancy (not secondary spread or metastatic) Lung Lymphoid and Histiocytic Tissue, other Lymphosarcoma Major Salivary Glands Male Breast Melanoma of Skin Metastic Disease, secondary spread Mouth, Floor of Multiple Myeloma Nasal Cavities, middle ear and accessory sinuses Nasopharynx Oropharynx Other Endocrine Glands and related structures Other and ill-defined sites within the digestive organs and peritoneum Other and ill-defined sites within the lip, oral cavity and pharynx Other and ill-defined sites Other and unspecified parts of mouth Other sites within the respiratory system and intrathoracic organs Other Specified Leukaemia Ovary Pancreas Placenta Pleura Prostate Recto Sigmoid Rectum Reticulosarcoma Retroperitoneum and Peritoneum 4 - 54 Code 205 208 203 140 155 162 202 200 142 175 172 199 144 203 160 147 146 194 159 149 195 145 165 207 183 157 181 163 185 154 154 200 158 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Neoplasm Unspecified Neoplasm Of Uncertain Behaviour Nephrotic Syndrome Neuralgia, Trigeminal Neurasthenia Neuritis, Idiopathic Peripheral Neuritis, Optic Neurodermatitis Neurosis Neutropenia Nocturia Non-psychotic Disorder Not Classified Elsewhere Nutritional and Vitamin Deficiencies Obesity February 2014 Description Secondary Cancer Secondary Neoplasm of Lymph Nodes Secondary Neoplasm of Respiratory and Digestive System Skin Malignancies, other Small Intestine, including duodenum Spinal Cord Stomach Testis Thymus, Heart and Mediastinum Thyroid Tongue Urinary Organs, other Uterus, body of Uterus, part unspecified Vagina Vulva Other Malignant Tumours (e.g., Polycythemia Vera) Digestive and Respiratory Systems Endocrine Glands and Nervous System Genitourinary Organs Other and Unspecified Sites and Tissues Anxiety, Obessive Compulsive Code 198 196 197 173 152 192 151 186 164 193 141 189 182 179 184 184 199 239 235 237 236 238 581 350 300 356 377 691 300 288 788 311 269 278 4 - 55 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Obsessive Compulsive Neurosis Obsessive Compulsive Personality Obstipation Obstructed Labour Obstruction Obstructive Pulmonary Disease Occupational Problems Oligomenorrhea Oligouria Onychogryposis Oophoritis Open Wounds Orchitis Osgood-Schlatter Disease Osteitis Deformans Osteoarthritis Osteochondritis, Osteochondritis Dissecans Osteomyelitis Osteoporosis Otitis Externa Otitis Media, Serous Otitis Media, Suppurative Otosclerosis Ovarian Dysfunction Overdose, Drug Pain Palsy February 2014 Description Code 300 301 Esophagus Intestine Lacrimal Duct Chronic, other Unemployment, difficulty at work Acute or chronic Except Limbs Lower Limb(s) Upper Limb(s) 564 660 530 560 375 496 905 626 786 703 614 879 894 884 604 732 731 715 732 730 730 380 381 382 Failure Abdominal Chest Joint, Leg, Muscle Bell's 4 - 56 387 256 977 787 785 781 351 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Pancreas Endocrine Disorders Paralysis, Facial Paralytic Ileus Paranoid Personality Disorder Paranoid States Paraphimosis Paraplegia Paratyphoid Fever Parathyroid Gland Disorders Parent-child Problems Description Cerebral 351 560 301 297 605 349 002 252 (e.g., Child Abuse, Battered Child, Child Neglect) Parkinson's Disease Paronychia Paroxysmal Tachycardia Patent Ductus Arteriosus Pediculosis Pelvic Inflammatory Disease (P.I.D.) Performation of Tympanic Membrane Pericarditis Perinatal Morbidity & Mortality, Due to Complications of Labour or Delivery Perinatal Disorders of Digestive System Periodontal Disease Peripheral Vascular Disease Peritonitis, With Or Without Abscess Personality Disorder (e.g., Obsessive Compulsive) February 2014 Code 343 251 4 - 57 899 332 686 427 747 132 614 384 429 763 777 523 443 567 301 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Pertussis Pes Planus Pharyngitis Phimosis Phlebitis Phobias, All Types P.I.D. Pilonidal Cyst or Abscess Pinworm Infestation Pituitary Gland Dysfunction Placenta Previa Pleurisy Description Paranoid Schizoid Pelvic Inflammatory Disease During Pregnancy 127 253 With or Without Effusion Tuberculosis Pleurodynia, Bronholm's Disease Pneumonia, All Types Pneumothorax, Spontaneous or Tension Poisoning Food Blood Poliomyelitis, Acute Polyarteritis Nodosa Polycythemia Vera Polycystic Ovaries Polymyalgia Rheumatic Polymyositis Polyp Anal or Rectal Cervical Nasal Porphyria Positive Conversion of T.B. Skin Test Postmaturity Pre-eclampsia (P.E.T.) Pregnancy Abnormality Bony Pelvis February 2014 Code 301 301 033 734 460 605 451 300 614 646 685 4 - 58 641 511 012 074 486 512 005 038 045 446 239 256 725 710 569 219 471 277 010 766 642 653 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Premature Labour Prematurity Premenstrual Tension Presbyopia Presenile Dementia Problems Prognathism Prolapse Prolonged Labour Prostatitis Pruritic (Itchy) Condition, Other Pruritus Ani Psoriasis Psychosis February 2014 Description Anemia of Ectopic Foetal Distress Multiple Other complications (e.g., Vulvitis, Vaginitis, Cervicitis, Pyelitis) Premature Rupture of Membranes Prolonged Pregnancy (post dates/post maturity pregnancy) Cystitis Uncomplicated Code 646 633 656 651 646 658 645 646 650 644 765 625 367 290 Aged Parent(s) 900 Economic 897 Educational 902 Family Disruption, Divorce 901 Illegitimacy 903 In-laws 900 Legal Problems, Litigation, Imprisonment 906 Occupational, Unemployment, Difficulty at Work 905 Parent/child (e.g., child-abuse, battered child, 899 child neglect) Social Maladjustment 904 Other problems of social adjustment 909 524 Rectal 569 Umbilical Cord 762 Uterine 618 662 601 698 698 696 291 Alcoholic 4 - 59 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Description Childhood Drug Korsakov's Manic Depressive Other Psychosomatic Disturbances Pterygium Ptosis, Eyelid Pulmonary Tuberculosis Pulmonary Embolism, Infarction P.U.O. (Pyrexia of Unknown Origin) Purpura Pyelitis 372 374 011 415 780 During Pregnancy Pyelonephritis, Acute or Chronic Pyoderma Pyogenic Arthritis Pyogenic Granuloma Quadriplegia Rabies Rash Raynaud's Disease Rectal Stricture, Prolapse, Bleeding Rectocele Recurrent Uveitis Refraction and Accommodation Disorder Renal Colic Renal Failure Acute Renal Failure Chronic Respiratory Distress Syndrome Retained Placenta February 2014 Code 299 292 291 296 298 306 287 590 634 590 686 711 686 349 079 691 443 569 618 972 367 788 584 585 769 667 4 - 60 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Retinal Detachment Retinitis Retrognathism Retroversion of Uterus Rheumatic Fever With Endocarditis, Myocarditis or Pericarditis Rheumatic Fever Without Endocarditis, Myocarditis or Pericarditis Rheumatic Heart Disease Rheumatism, Muscular Rhinitis, Allergic Ringworm Description 390 Other 398 Scalp, Beard, Foot Other 729 477 110 117 057 056 Roseola Rubella (German Measles) Rubeoloa (Measles) Salivary Gland, Diseases of Salmonella Infections Salpingitis Acute, or chronic (fallopian tube) Eustachian Sarcoidosis Scabies Scar, Scarring Scarlet Fever Schizoid Personality Disorder Schizophrenia Sciatica Scleroderma Localized Generalized Scoliosis Sebaceous Cyst February 2014 Code 361 363 524 621 391 4 - 61 055 527 003 614 384 135 133 709 034 301 295 724 701 710 737 706 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Seborrheic Dermatitis Seminal Vesiculitis Senescence Senile Dementia Senility Septal Defect, Atrial or Ventricular Septicemia Sexual Deviations Sexual Dysfunction Shingles Shock Shortness of Breath Silicosis Sinusitis Acute Sinusitis Chronic Skin, Dry Sleep Disorders Social Adjustment Problem Social Maladjustment Spasms, Muscle Spastic Colon Spermatocele Spina Bifida With or Without Hydrocephalus Spondylitis Spondyloarthropathies Spondylosis Sprains - See Strains Sprue Staphlococcal Infection Stasis Ulcer Stein-Leventhal Syndrome Stenosis February 2014 Description Other than those individually specified in this list Code 690 608 797 290 797 745 038 302 306 053 785 786 502 461 473 701 307 909 904 728 564 608 741 Ankylosing Sero-Negative 720 721 718 579 038 454 256 Esophagus Mitral Pulmonary Artery Vagina 4 - 62 530 394 747 623 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Sterilization Advice Sterility Still's Disease Sting, Bee Or Wasp Stomal Ulcer Stomatitis Stone (Calculus) Strabismus Strains, Sprains and Other Trauma Streptococcal Sore Throat Stress Incontinence Stricture Stroke, C.V.A. Stuttering Stye Sudden Death, Cause Unknown Suicide, Attempted Description In Kidney or Ureter (Cholelithiasis) with or without Cholecystitis Ankle, Foot, Toes Coccyx Knee, Leg Neck Shoulder, Upper Arm Wrist, Hand, Fingers Other Anal or Rectal Esophagus Urethral Vagina Chemicals Drugs Tendencies Trauma Sweating, Excessive Swine Flu Syncope Synovitis Syphilis, All Sites and Stages Syringomyelia February 2014 Code 895 628 714 989 534 528 592 574 378 845 847 844 847 840 842 848 034 625 569 530 598 623 436 307 373 798 989 977 300 959 799 487 785 727 097 349 4 - 63 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Tachycardia Description Not yet diagnosed Paroxysmal Taenia Tapeworm Infestation, All Types Tay-Sachs Disease Teeth, Other Diseases of Hard Tissues Teeth and Supporting Structures Other Conditions Teething Temporomandibular Joint Disorders Tenosynovitis Testicular Dysfunction Tetanus Tetralogy of Fallot Thalassemia Threatened Labour Thrombocytopenia Thrombophlebitis Thrombosis Thrombosis of Portal Vein Thrush Thyroiditis Thyrotoxicosis Tic Douloureux Tics Tinnitus Tobacco Abuse Tongue, Other Conditions of Tonsillitis February 2014 Code 785 427 123 123 330 521 525 525 524 Post Partum Cerebral Coronary 727 257 037 745 282 644 287 451 671 436 410 452 112 245 242 350 307 388 305 529 463 Acute 4 - 64 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Tonsils And/or Adenoids, Hypertrophy or Chronic Infection Torsion of Cord or Testis Torticollis (Wry Neck) Toxaemia of Pregnancy Toxoplasmosis Tracheitis, Acute Transient Cerebral Ischaemia Transportation of Great Vessels Traumatic Arthritis Trichomonas Infection Tuberculosis Turner's Syndrome Typhoid Fever, Paratyphoid Ulcer Description 608 739 642 130 464 435 745 Bones and Joints Other Organs Pleurisy - with or without effusion Pulmonsary Recent positive conversion of T.B. skin Respiratory Test Aphthous Corneal Decubitus Duodenal with or without haemorrhage or perforation Esophagus Gastric with or without haemorrhage or perforation Stasis Stomal, Gastrojejunal Hunner's Undescended Testicle Unemployment Problems February 2014 Code 474 4 - 65 716 131 015 017 012 011 012 010 758 002 528 370 707 532 530 531 454 534 595 608 905 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Unusual Position Of Fetus Upper Respiratory Infection Urachal Cyst Uremia Urethral Stricture Urethritis, Non-specific Urethrocele Urinary Retention Urticaria, Allergic Uterine Vaginitis Varicose Veins Vasculitis Vaso Vagal Attack Ventricular Flutter, Fibrillation Verruca Vertigo Vesiculitis, Seminal Vestibulitis Vincent's Angina Viremia Visual Field Defects Vitamin and Other Nutritional Deficiencies Volvulus Vomiting Vomiting, as a Complication of Pregnancy Vulvitis Warts February 2014 Description Code 652 460 Not sexually transmitted Fibroid Inertia Prolapse (Not trichomonas - see 131) With Pregnancy With Pregnancy Of lower extremities, with or without ulcer 753 585 598 597 618 788 708 218 661 618 616 646 646 454 447 780 427 078 780 608 386 136 790 368 269 560 787 643 Unrelated to Pregnancy With Pregnancy All Types Seborrheic 4 - 66 616 646 078 216 Version 1.0 Claims Submission Resource Manual for Physicians Alpha Diagnosis Description Venereal, Other Disorders Wasp Sting Wax in Ear Well Vision Care Whiplash Whooping Cough Wry Neck (Torticollis) February 2014 4 - 67 Code 629 989 388 917 847 033 739 Version 1.0 Claims Submission Resource Manual for Physicians Other Diseases or Disorders - Not Specified Elsewhere Diagnosis Adrenal Gland Amino Acid Metabolism Arteries Bacterial Diseases Behaviour of Childhood and Adolescence Bile Ducts Blood Bone and Cartilage Breast Circulatory System Conduction Congenital Anomalies Conjunctiva Connective Tissue Cranial Nerves Depressive Digestive System Duodenum Ear Endocrine Eustachian Tube Eye Eyelid Facial Nerves Fetus or Newborn Gallbladder General Symptoms Genital Organs, Female Genital Organs, Male Genito-urinary System Heart Disease Helminthiases Immunity Infective Disease Injuries Intervertebral Disc Intestine February 2014 Description Other Not elsewhere classified Signs and symptoms not yet diagnosed Signs and symptoms not yet diagnosed 4 - 68 Code 255 270 447 040 313 576 289 733 611 459 426 759 372 739 352 311 787 537 388 259 381 379 374 351 779 576 799 629 608 788 429 128 279 136 959 722 569 Version 1.0 Claims Submission Resource Manual for Physicians Other Diseases or Disorders - Not Specified Elsewhere Diagnosis Intestines Kidney Lipoid Metabolism Liver Marrow Mastoid Menstruation Metabolic Disorders Musculoskeletal System Mycoses Myoneural Nervous System, Central Newborn Non-psychotic Pancreas Parasitic Diseases Personality Disorders Pituitary Gland Psychoses Refraction and Accommodation Respiratory System Skin and Subcutaneous Tissue Description Other vascular conditions Not elsewhere classified Signs and Symptoms not yet diagnosed Other disorders Other itchy conditions Other local infections Sleep Spleen Stomach Teeth and Supporting Structures Trauma Ureter Urinary Tract Uterus Venereal Viral Disease Of central nervous system, non-arthropodborne Well Baby Care February 2014 Code 557 593 272 573 289 388 626 277 739 117 358 349 779 311 577 136 301 253 298 367 519 786 709 698 686 307 289 537 525 959 593 599 621 099 079 049 916 4 - 69 Version 1.0 Claims Submission Resource Manual for Physicians Infections and Parasitic Diseases Diagnosis Intestinal Infectious Diseases Tuberculosis Other Bacterial Diseases Human Immunodeficiency Virus (HIV) Infection Non-arthropod-borne Viral Diseases of Central Nervous System Viral Diseases Accompanied by Rash Other Viral Diseases February 2014 Description Typhoid and paratyphoid fevers Other salmonella infections Food poisoning Amoebiasis, amoebic dysentery Diarrhea, gastro-enteritis, viral gastro-enteritis Primary tuberculous infection, including recent positive TB skin test conversion Pulmonary tuberculosis Other respiratory tuberculosis, tuberculous pleurisy with or without effusion Tuberculosis of bones and joints Tuberculosis of other organs Brucellosis Leprosy (Hansen's Disease) Diphtheria Whooping cough, pertussis Streptococcal sore throat, scarlet fever Erysipelas Meningococcal infection or meningitis Tetanus Septicemia, blood poisoning Actinomycotic infections Other bacterial diseases AIDS AIDS-related complex (ARC) Other human immunodeficiency virus infection Acute poliomyelitis Meningitis due to enterovirus Other non-arthropod-borne viral diseases of central nervous system Chickenpox Herpes zoster, shingles Herpes simplex, cold sore Measles German measles, rubella Other viral disorders accompanied by rash (e.g., roseola) Mosquito-borne viral encephalitis 4 - 70 Code 002 003 005 006 009 010 011 012 015 017 023 030 032 033 034 035 036 037 038 039 040 042 043 044 045 047 049 052 053 054 055 056 057 062 Version 1.0 Claims Submission Resource Manual for Physicians Infections and Parasitic Diseases Diagnosis Venereal Diseases Mycoses Helminthiases Other Infectious and Parasitic Diseases Description Other arthropod-borne viral diseases Viral hepatitis Mumps Diseases due to Coxsackie virus: pleurodynia, myocarditis Infectious mononucleosis, glandular fever Warts Other viral diseases Syphilis - all sites and stages Gonococcal infections Other venereal diseases (e.g., herpes genitalis) Diagnostic code 100 is for internal use only and should be used when it is requested that the service or diagnosis on the incoming claim be suppressed from verification. The usage of the code is monitored Ringworm of scalp, beard, or foot Candidiasis, monilia infection - all sites, thrush Histoplasmosis Other mycoses Echinococcosis, hydadid cyst - all sites Taenia or tapeworm infestation - all types Pinworm infestation Other helminthiases Toxoplasmosis Trichomonas infection Head or body lice, pediculosis Scabies, acariasis Sarcoidosis Other infectious or parasitic diseases Code 066 070 072 074 Description Lip Tongue Major salivary glands Gum Floor of mouth Code 140 141 142 143 144 075 078 079 097 098 099 100 110 112 115 117 122 123 127 128 130 131 132 133 135 136 Neoplasms Diagnosis Malignant Neoplasms February 2014 4 - 71 Version 1.0 Claims Submission Resource Manual for Physicians Neoplasms Diagnosis February 2014 Description Other and unspecified parts of mouth Oropharynx Nasopharynx Hypopharynx Other and ill-defined sites within the lip, oral cavity, and pharynx Esophagus Stomach Small intestine, including duodenum Large intestine - excluding rectum Rectum, rectosigmoid and anus Primary malignancy of liver (not secondary spread or metastatic disease) Gallbladder and extra hepatic bile ducts Pancreas Retroperitoneum and peritoneum Other and ill-defined sites within the digestive organs and peritoneum Nasal cavities, middle ear, and accessory sinuses Larynx, trachea Bronchus, lung Pleura Thymus, heart, and mediastinum Other sites within the respiratory system and intrathoracic organs Bone Connective and other soft tissue Melanoma of skin Other skin malignancies Female breast Male breast Uterus, part unspecified Cervix Placenta Body of uterus Ovary, fallopian tube, broad ligament Vagina, vulva, other female genital organs Prostate Testis 4 - 72 Code 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 170 171 172 173 174 175 179 180 181 182 183 184 185 186 Version 1.0 Claims Submission Resource Manual for Physicians Neoplasms Diagnosis Benign Neoplasms February 2014 Description Other male genital organs Bladder Kidney, other urinary organs Eye Brain Cranial nerves, spinal cord, other parts of nervous system Thyroid Other endocrine glands and related structures Other ill-defined sites Secondary neoplasm of lymph nodes Secondary neoplasm of respiratory and digestive systems Metastatic or secondary malignant neoplasm, carcinomatosis Other malignant neoplasms Lymphosarcoma, reticulosarcoma Hodgkin's disease Other malignant neoplasms of lymphoid and histiocytic tissue Multiple myeloma, plasma cell leukemia Lymphoid leukemia (including lymphatic and histiocytic leukemia) Myeloid leukemia (including granulocytic and myelogenous leukemia) Monocytic leukemia Other specified leukemia Other types of leukemia Lip, oral cavity, pharynx Other parts of digestive system, peritoneum Respiratory and intra-thoracic organs Bone, cartilage Lipoma Connective and other soft tissue Skin (e.g., pigmented naevus, dermatofibroma) Breast Uterine fibroid, leiomyoma Other benign neoplasms of uterus (e.g., cervical polyp) Ovary (e.g., ovarian cyst) 4 - 73 Code 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 210 211 212 213 214 215 216 217 218 219 220 Version 1.0 Claims Submission Resource Manual for Physicians Neoplasms Diagnosis Carcinoma in Situ Neoplasms of Uncertain Behavior Description Other benign neoplasms of female genital organs Benign neoplasms of male genital organs Kidney, ureter, bladder Eye Brain, spinal cord, peripheral nerves Thyroid (e.g., adenoma or cystadenoma) Other endocrine glands and related structures Haemangioma and lymphangiomax Other benign neoplasms Digestive organs Respiratory system Skin Breast and genito-urinary system Other Digestive and respiratory systems Genitourinary organs Endocrine glands and nervous system Other and unspecified sites and tissues Unspecified neoplasms (e.g., polycythemia vera) Code 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 Endocrine, Nutritional and Metabolic Diseases and Immunity Disorders Diagnosis Endocrine Glands February 2014 Description Simple thyroid goitre Nontoxic nodular goitre Hyperthyroidism, thyrotoxicosis, exophthalmic goitre Hypothyroidism - congenital (i.e., cretinism) Hypothyroidism - acquired (i.e., myxedema) Thyroiditis Pre-diabetes Diabetes mellitus, including complications Other disorders of pancreatic internal secretions (e.g., insulinoma neo-natal hypoglycemia, Zollinger -Ellison syndrome) Parathyroid gland disorders (e.g., hyperparathyroidism, hypoparathyroidism) 4 - 74 Code 240 241 242 243 244 245 249 250 251 252 Version 1.0 Claims Submission Resource Manual for Physicians Endocrine, Nutritional and Metabolic Diseases and Immunity Disorders Diagnosis Nutritional and Metabolic Disorders Immunity Disorders Description Pituitary gland disorders (e.g., acromegaly, dwarfism, diabetes insipidus) Adrenal gland disorders (e.g., Cushing's syndrome, hyperaldosteronism, Conn's syndrome, adrenogenital syndrome, Addison's disease) Ovarian dysfunction (e.g., ovarian failure, polycystic ovaries, Stein-Leventhal syndrome) Testicular dysfunction Other endocrine disorders Unspecified malnutrition Vitamin and other nutritional deficiencies Disorders of amino-acid metabolism (e.g., cystinuria, Fanconi syndrome) Disorders of lipoid metabolism (e.g., hypercholesterolemia, lipoprotein disorders) Gout Other metabolic disorders Obesity Hypogammaglobulinemia, agammaglobulinemia, other immunity disorders Code 253 255 256 257 259 263 269 270 272 274 277 278 279 Diseases of Blood And Blood-Forming Organs Diagnosis Diseases of Blood and Blood-Forming Organs February 2014 Description Iron deficiency anaemia Pernicious anaemia Hereditary hemolytic anaemia (e.g., thalassemia, sickle-cell anaemia) Acquired hemolytic anaemia, excluding hemolytic disease of newborn Aplastic anaemia Other anaemias Coagulation defects (e.g., hemophilia, other factor deficiencies) Purpura, thrombocytopenia, other hemorrhagic conditions Neutropenia, acranulocytosis, eosinophilia Other diseases of blood, marrow, spleen 4 - 75 Code 280 281 282 283 284 285 286 287 288 289 Version 1.0 Claims Submission Resource Manual for Physicians Mental Disorders Diagnosis Psychoses Neuroses and Personality Disorders Neuroses and Personality Disorders (Continued) Description Senile dementia, presenile dementia Alcoholic psychosis, delirium tremens, Korsakov's psychosis Drug psychosis Schizophrenia Manic depressive psychosis, involutional melancholia Paranoid states Other psychoses Childhood psychoses (e.g., autism) Anxiety neurosis, hysteria, neurasthenia, obsessive compulsive neurosis, reactive depression Personality disorders (e.g., paranoid personality, schizoid personality, obsessive compulsive personality) Sexual deviations Alcoholism Drug dependence, drug addiction Tobacco abuse Psychosomatic disturbances Habit spasms, tics, stuttering, tension headaches, anorexia nervosa, sleep disorders, enuresis Adjustment reaction Depressive or other non-psychotic disorders, not elsewhere classified Behaviour disorders of childhood and adolescence Hyperkinetic syndrome of childhood Specified delays in development (e.g., dyslexia, dyslalia, motor retardation) Mental retardation Code 290 291 292 295 296 297 298 299 300 301 302 303 304 305 306 307 309 311 313 314 315 319 Diseases of the Nervous System and Sense Organs Diagnosis Central Nervous System February 2014 Description Bacterial meningitis Meningitis due to other organisms Encephalitis, encephalomyelitis 4 - 76 Code 320 321 323 Version 1.0 Claims Submission Resource Manual for Physicians Diseases of the Nervous System and Sense Organs Diagnosis Peripheral Nervous System Eye February 2014 Description Tay-Sachs disease Other cerebral degenerations Parkinson's disease Multiple sclerosis Cerebral palsy Epilepsy Migraine Other diseases of central nervous system (e.g., brain abscess, narcolepsy, motor neuron disease, syringomyelia) Trigeminal neuralgia, tic douloureux Bell's palsy, facial nerve disorders Disorders of other cranial nerves Idiopathic peripheral neuritis Myoneural disorders (e.g., myasthenia gravis) Muscular dystrophies Aphakia Retinal detachment Hypertensive retinopathy and other retinal diseases not specifically listed Chorioretinitis Iritis Glaucoma Cataract, excludes diabetic or congenital Myopia, astigmatism (except for the specific conditions defined by diagnostic code 371), presbyopia and other disorders of refraction and accommodation Amblyopia, visual field defects Blindness and low vision Keratitis, corneal ulcer High Myopia greater than 9 diopters; Irregular Astigmatism resulting from corneal grafting or corneal scarring from diseases Conjunctiva disorders (e.g., conjunctivitis, pterygium) Blepharitis, chalazion, stye Other eyelid disorders (e.g., entropion, ectropion, ptosis) Dacryocystitis, obstruction of lacrimal duct 4 - 77 Code 330 331 332 340 343 345 346 349 350 351 352 356 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 Version 1.0 Claims Submission Resource Manual for Physicians Diseases of the Nervous System and Sense Organs Diagnosis Ear and Mastoid Signs and Symptoms Not Yet Diagnosed Description Keratoconus Optic neuritis Strabismus Other disorders of the eye Otitis externa Serous otitis media, eustachian tube disorders Suppurative otitis media Mastoiditis Perforation of tympanic membrane Meniere's disease, labyrinthitis Otosclerosis Wax or cerumen in ear, other disorders of ear and mastoid, tinnitus Deafness Convulsions, ataxia, vertigo, headache, except tension headache and migraine Code 376 377 378 379 380 381 382 383 384 386 387 388 389 780 Diseases of the Circulatory System Diagnosis Rheumatic Fever and Rheumatic Heart Disease Hypertensive Disease Ischaemic and Other Forms of Heart Disease Ischaemic and Other Forms of Heart Disease February 2014 Description Rheumatic fever without endocarditis, myocarditis or pericarditis Rheumatic fever with endocarditis, myocarditis, or pericarditis Chorea Mitral stenosis, mitral insufficiency Other rheumatic heart disease Essential, benign hypertension Hypertensive heart disease Hypertensive renal disease Acute myocardial infarction Old myocardial infarction, chronic coronary artery disease of arteriosclerotic heart disease, without symptoms Acute coronary insufficiency, angina pectoris, acute ischaemic heart disease Pulmonary embolism, pulmonary infarction Heart blocks, other conduction disorders Paroxysmal tachycardia, atrial or ventricular flutter or fibrillation, cardiac arrest, other arrythmias 4 - 78 Code 390 391 392 394 398 401 402 403 410 412 413 415 426 427 Version 1.0 Claims Submission Resource Manual for Physicians Diseases of the Circulatory System Diagnosis Cerebrovascular Disease Diseases of Arteries Diseases of Veins and Lyphatics Signs and Symptoms Not Yet Diagnosed Description Congestive heart failure All other forms of heart disease Intracranial Haemorrhage Transient cerebral ischaemia Acute cerebrovascular accident, C.V.A., stroke Chronic arteriosclerotic cerebrovascular disease, hypertensive encephalopathy Generalized arteriosclerosis, atherosclerosis Aortic aneurysm (non-syphilitic) Raynaud's disease, Buerger's disease, peripheral vascular disease, intermittent claudication Polyarteritis nodosa, temporal arteritis Other disorders of arteries Phlebitis, thrombophlebitis Portal vein thrombosis Varicose veins of lower extremities with or without ulcer Haemorrhoids Lymphangitis, lymphedema Other disorders of circulatory system Chest pain, tachycardia, syncope, shock, edema, masses Code 428 429 432 435 436 437 440 441 443 446 447 451 452 454 455 457 459 785 Diseases of the Respiratory System Diagnosis February 2014 Description Acute nasopharyngitis, common cold Acute sinusitis Acute tonsillitis Acute laryngitis, tracheitis, croup, epiglottis Acute bronchitis Deviated nasal septum Nasal polyp Chronic sinusitis Hypertrophy or chronic infection of tonsils and/or adenoids Allergic rhinitis, hay fever Pneumonia - all types Influenza Chronic bronchitis 4 - 79 Code 460 461 463 464 466 470 471 473 474 477 486 487 491 Version 1.0 Claims Submission Resource Manual for Physicians Diseases of the Respiratory System Diagnosis Signs and Symptoms Not Yet Diagnosed Description Emphysema Asthma, allergic bronchitis Bronchiectasis Other chronic obstructive pulmonary disease Asbestosis Silicosis Pleurisy with or without effusion Spontaneous pneumothorax, tension pneumothorax Pulmonary fibrosis Atelectasis, other diseases of lung Other diseases of respiratory system Epistaxis, hemoptysis, cough, dyspnea, masses, shortness of breath, hyperventilation, sleep apnea Code 492 493 494 496 501 502 511 512 515 518 519 786 Diseases of the Digestive System Diagnosis Diseases of Oral Cavity, Salivary Glands and Jaws Diseases of Esophagus, Stomach and Duodenum February 2014 Description Dental caries, other diseases of hard tissues of teeth (system inserted for dentists' claims) Gingivitis, periodontal disease Prognathism, micrognathism, macrognathism, retrognathism, malocclusion, temporomandibular joint disorders Other conditions of teeth and supporting structure Disease of salivary glands Stomatitis, aphthous ulcers, canker sore, diseases of lips Glossitis, other conditions of the tongue Esophagitis, cardiospasm, ulcer of esophagus; stricture, stenosis, or obstruction of esophagus Gastric ulcer, with or without haemorrage or perforation Duodenal ulcer, with or without haemorrhage or perforation Stomal ulcer, gastrojejunal ulcer Gastritis Hyperchlorhydria, hypochlorhydria, dyspepsia, indigestion Other disorders of stomach and duodenum 4 - 80 Code 521 523 524 525 527 528 529 530 531 532 534 535 536 537 Version 1.0 Claims Submission Resource Manual for Physicians Diseases of the Digestive System Diagnosis Hernia Other Diseases of Intestine and Peritoneum Other Diseases of Digestive System Signs and Symptoms Not Yet Diagnosed Description Inguinal hernia, with or without obstruction Femoral, umbilical, ventral, diaphragmatic or hiatus hernia with obstruction Femoral, umbilical, ventral, diaphragmatic or hiatus hernia without obstruction Acute appendicitis, with or without abscess or peritonitis Regional enteritis, Crohn's disease Ulcerative colitis Mesenteric artery occlusion, other vascular conditions of intestine Intestinal obstruction, intussusception, paralytic ileus, volvulus, impaction of intestine Diverticulitis or diverticulosis of large or small intestine Spastic colon, irritable colon, mucous colitis, constipation Anal fissure, anal fistula Abscess of anal or rectal regions Peritonitis, with or without abscess Anal or rectal polyp, rectal prolapse, anal or rectal stricture, rectal bleeding, other disorders of intestine Cirrhosis of the liver (e.g., alcoholic cirrhosis, biliary cirrhosis) Other diseases of the liver Cholelithiasis (gall stones) with or without cholecystitis Cholecystitis, without gall stones Other diseases of gallbladder and biliary ducts Diseases of pancreas Malabsorption syndrome, sprue, celiac disease Anorexia, nausea and vomiting, heartburn, dysphagia, hiccough, hematemesis, jaundice, ascites, abdominal pain, melena, masses Code 550 552 553 540 555 556 557 560 562 564 565 566 567 569 571 573 574 575 576 577 579 787 Diseases of the Genito - Urinary System Diagnosis Diseases of the Urinary System February 2014 Description Acute glomerulonephritis Nephrotic Syndrome 4 - 81 Code 580 581 Version 1.0 Claims Submission Resource Manual for Physicians Diseases of the Genito - Urinary System Diagnosis Diseases of the Urinary System (Continued) Diseases of Male Genital Organs Diseases of Breast and Female Pelvic Organs Other Disorders of Female Genital Tract February 2014 Description Acute renal failure Chronic renal failure, uremia Acute or chronic pyelonephritis, pyelitis, abscess Hydronephrosis Stone in kidney or ureter Other disorders of kidney or ureter Cystitis Non-specific urethritis (not sexually transmitted) Urethral stricture Other disorders of urinary tract Benign prostatic hypertrophy Prostatitis Hydrocele Orchitis, epididymitis Phimosis, paraphimosis Male infertility, oligospermia, azoospermia Seminal vesiculitis, spermatocele, torsion of cord or testis, undescended testicle, other disorders of male genital organs Newborn circumcision Cystic mastitis, chronic cystic disease, breast cyst, fibro-adenosis of breast Breast abscess, gynecomastia, hypertrophy, other disorders of breast Acute or chronic salpingitis or oophoritis or abscess, pelvic inflammatory disease Acute or chronic endometritis Cervicitis, vaginitis, cyst or abscess of Bartholin's gland, vulvitis Endometriosis Cystocele, rectocele, urethrocele, enterocele, uterine prolapse Retroversion of uterus, endometrial hyperplasia, other disorders of uteru Cervical erosion, cervical dysplasia Stricture or stenosis of vagina Dyspareunia, dysmenorrhea, premenstrual tension, stress incontinence 4 - 82 Code 584 585 590 591 592 593 595 597 598 599 600 601 603 604 605 606 608 609 610 611 614 615 616 617 618 621 622 623 625 Version 1.0 Claims Submission Resource Manual for Physicians Diseases of the Genito - Urinary System Diagnosis Other Disorders of Female Genital Tract (Continued) Signs and Symptoms Not Yet Diagnosed Description Disorders of menstruation Menopause, post-menopausal bleeding Infertility Other disorders of female genital organs Code 626 627 628 629 Chorioretinitis 636 Renal colic, urinary retention, nocturia, masses 788 Complications of Pregnancy, Childbirth and the Puerperium Diagnosis February 2014 Description Missed abortion Ectopic pregnancy Incomplete abortion, complete abortion Therapeutic abortion Threatened abortion, haemorrhage in early pregnancy Abruptio placentae, placenta praevia Pre-eclampsia, eclampsia, toxaemia Vomiting, hyperemesis gravidarum False labour, threatened labour Prolonged pregnancy Other complications of pregnancy (e.g., vulvitis, vaginitis, cervicitis, pyelitis, cystitis) Normal delivery, uncomplicated pregnancy Multiple pregnancy Unusual position of fetus, malpresentation Cephalo-pelvic disproportion Foetal distress Premature rupture of membrane Obstructed labour Uterine inertia Prolonged labour Perineal lacerations Post-Partum haemorrhage Retained placenta Delivery with other complications Post-Partum thrombophlebitis Post-Partum mastitis or nipple infection 4 - 83 Code 632 633 634 635 640 641 642 643 644 645 646 650 651 652 653 656 658 660 661 662 664 666 667 669 671 675 Version 1.0 Claims Submission Resource Manual for Physicians Complications of Pregnancy, Childbirth and the Puerperium Diagnosis Description Post-Partum pulmonary Code 677 Diseases of the Skin and Subcutaneous Tissue Diagnosis Infections Other Inflammatory Conditions Other Diseases of Skin and Subcutaneous Tissue Description Boil, carbuncle, furunculosis Cellulitis, abscess Acute lymphadenitis Impetigo Pilonidal cyst or abscess Pyoderma, pyogenic granuloma, other local infections Seborrheic dermatitis Eczema, atopic dermatitis, neurodermatitis Contact dermatitis Erythema multiforme, erythema nodosum, acne, rosacea, lupus erythematosus, intertrigo Psoriasis Pruritus ani, other itchy conditions Corns, calluses Hyperkeratosis, scleroderma, keloid Ingrown nail, onychogryposis Alopecia Acne, acne vulgaris, sebaceous cyst Debcubitus ulcer, bed sore Allergic urticaria Other disorders of skin and subcutaneous tissue Code 680 682 683 684 685 686 690 691 692 695 696 698 700 701 703 704 706 707 708 709 Diseases of Muscoloskeletal System and Connective Tissue Diagnosis February 2014 Description Desseminated lupus erythematosus, generalized scleroderma, dermatomyositis, polymostitis Pyogenic arthritis Rheumatoid arthritis, Still's disease Osteoarthritis Traumatic arthritis Joint derangement, recurrent dislocation, ankylosis, meniscus or cartilage tear, loose body in joint 4 - 84 Code 710 711 714 715 716 718 Version 1.0 Claims Submission Resource Manual for Physicians Diseases of Muscoloskeletal System and Connective Tissue Diagnosis Signs and Symptoms Not Yet Diagnosed Description Ankylosing spondylitis Sero- negative Spondyloarthropathies Intervertebral disc disorders Lumbar strain, lumbago, coccydynia, sciatica Synovitis, tenosynovitis, bursitis, bunion, ganglion Dupuytren's contracture Fibrositis, myositis, muscular rheumatism Osteomyelitis Osteitis deformans, Paget's disease of bone Osteochondritis, Legg-Perthes disease, Osgood-Schlatter disease, osteochondritis dissecans Osteoporosis, spontaneous fracture, other disorders of bone and cartilage Flat foot, pes planus Hallux valgus, hallux varus, hammer toe Scoliosis, kyphosis, lordosis Other diseases of musculoskeletal system and connective tissue Leg cramps, leg pain, muscle pain, joint pain, arthralgia, joint swelling, masses Code 720 721 722 724 727 Description Spina bifida, with or without hydrocephalus, meningocele, meningomyelocele Hydrocephalus Congenital anomalies of eye Congenital anomalies of ear, face, and neck Transposition of great vessels, tetralogy of Fallot, ventricular septal defect, atrial septal defect Other congenital anomalies of heart Patent ductus arteriosus, coarctation of aorta, pulmonary artery stenosis, other anomalies of circulatory system Congenital anomalies of nose and respiratory system Cleft palate, cleft lip Code 741 728 729 730 731 732 733 734 735 737 739 781 Congenital Anomalies Diagnosis Congenital Anomalies February 2014 4 - 85 742 743 744 745 746 747 748 749 Version 1.0 Claims Submission Resource Manual for Physicians Congenital Anomalies Diagnosis Description Other congenital anomalies of mouth esophagus, stomach and pylorus Digestive system Genital organs Urinary system Club foot Other congenital anomalies of limbs Other musculoskeletal anomalies Chromosomal anomalies (e.g., Down's syndrome, other autosomal anomalies, Klinefelter's syndrome, Turner's syndrome, other anomalies of sex chromosomes) Other congenital anomalies Code 750 751 752 753 754 755 756 758 759 Perinatal Morbidity and Mortality Diagnosis Description Compression of umbilical cord, prolapsed cord Due to complications of labour or delivery Prematurity, low-birthweight infant Postmaturity, high-birthweight infant Birth trauma Hyaline membrane disease, respiratory distress syndrome Hemolytic disease of newborn Perinatal disorders of digestive system Other conditions of fetus or newborn Code 762 763 765 766 767 769 773 777 779 Symptoms, Signs and Ill-Defined Conditions Diagnosis Non-specific Abnormal Findings February 2014 Description Non-specific findings on examination of blood Non-specific findings on examination of urine Chronic fatigue symdrome Other non-specific abnormal findings Senility, senescence Sudden death, cause unknown Other ill-defined conditions 4 - 86 Code 790 791 795 796 797 798 799 Version 1.0 Claims Submission Resource Manual for Physicians Accidents, Poisonings and Violence Diagnosis Fractures and Fracturedislocations Fractures and Fracturedislocations (Continued) Dislocations Sprains, Strains and Other Trauma February 2014 Description Facial bones Skull Vertebral column - without spinal cord damage Vertebral column - with spinal cord damage Ribs Pelvis Clavicle Humerus Radius and/or ulna Carpal bones Metacarpals Phalanges - foot or hand Femur Tibia and/or fibula Ankle Other fractures Shoulder Elbow Finger Other dislocations Shoulder, upper arm Wrist, hand, fingers Knee, leg Ankle, foot, toes Neck, low back, coccyx Other sprains and strains Concussion Other head injuries Internal injuries to organ(s) Lacerations, open wounds - except limbs Lacerations, open wounds, traumatic amputations upper limb(s) Lacerations, open wounds, traumatic amputations - lower limb(s) Automated Visual Field (AVF) test Abrasions, bruises, contusions and other superficial injury including non-venomous bites Foreign body in eye, or other tissues Burns - thermal or chemical 4 - 87 Code 802 803 805 806 807 808 810 812 813 814 815 816 821 823 824 829 831 832 834 839 840 842 844 845 847 848 850 854 869 879 884 894 918 919 930 949 Version 1.0 Claims Submission Resource Manual for Physicians Accidents, Poisonings and Violence Diagnosis Adverse Effects Description Other injuries or trauma Of drugs and medications - including allergy, overdose, reactions Of other chemicals (e.g., lead, pesticides, and venomous bites) Of physical factors (e.g., heat, cold, frostbite, pressure) Of surgical and medical care (e.g., wound infection, wound disruption, other iatrogenic disease) Code 959 977 989 994 998 Supplementary Classifications Diagnosis Family Planning Immunization Social, Marital and Family Problems Other February 2014 Description Family planning, contraceptive advice, advice on sterilization or abortion Immunization - all types Pentavalent (DPT POLIO/ACT HIB) DPT Polio DT MMR (Measles, Mumps, Rubella) Hepatitis B TD Polio TD (Adults and aged 7 years and older) Influenza Pneumococcal Other Immunization – Not Defined Economic problems Marital difficulties Parent-child problems (e.g., child-abuse, battered child, child neglect) Problems with aged parents or in-laws Family disruption, divorce Educational problems Illegitimacy Social maladjustment Occupational problems, unemployment, difficulty at work Legal problems, litigation, imprisonment Other problems of social adjustment Well baby care 4 - 88 Code 895 896 960 961 962 963 964 965 966 967 968 969 897 898 899 900 901 902 903 904 905 906 909 916 Version 1.0 Claims Submission Resource Manual for Physicians Supplementary Classifications Diagnosis Description Annual health examination adolescent/adult Well Vision Care Code 917 Physiotherapy Diagnosis Operations on the Musculoskeletal System Other Acceptable Diagnosis Common Diagnostic Codes Arthritis February 2014 Description Code Osteotomy 893 Excision Bunion 894 Excision of Bone Partial 897 Excision of Bone Complete (e.g., 898 Patellectomy) Excision or Destruction of Intervertebral Disc 923 Excision of Semilunar Cartilage of Knee Synovectomy 924 Spinal Fusion 930 Arthrodesis of Foot and Ankle 931 Arthrodesis of Other Joints 932 Arthroplasty of Foot and Toe 933 Arthroplasty of Knee and Ankle (e.g., Hauser 934 Repair) Total Hip Replacement 935 Other Arthroplasty of Hip 936 Incision of Muscle, Tendon, Fascia, ................... 940 Division of Muscle, Tendon, and Fascia of 941 Hand Suture of Muscle, Tendon, and Fascia of Hand 944 Transplantation of Muscle and Tendon of Hand 945 Gait Training or CrutchWalking Instruction 072 (acceptable for a 1 visit treatment only) Perceptual Motor Testing or Perceptual Motor 070 Assessment of Dysfunction Prenatal Care 970 Post-Partum Observation 971 Osteo-degenerative Cervical Gouty Rheumatic Non-specified Acute Non-specified Chronic 7159 7210 7120 7149 7169 7150 4 - 89 Version 1.0 Claims Submission Resource Manual for Physicians Physiotherapy Diagnosis Bells Palsy Bursitis Calcaneal Calcium Capsulitis Cervical Disc Disease Cervical Strain Chest Disease Chondromalacia Compression Fracture Cervical Contusion Knee Dislocated Shoulder Epicondylitis Fibrositis Frozen Shoulder Fracture Gout Hamstring - Tendon Headache Injury Description Spur Bone Bursa Joint Ankle (closed) Humerus (unspecified) Leg Vertebra Wrist Elbow Shoulder Kyphosis (acquired) Lumbago Lumbar Disc Disease (degenerative) Lumbar Strain Lymphedema Muscle Spasm Muscle Strain Myositis Plain and Trauma Neuralgia (unspecified) Pagets Disease February 2014 Code 3510 7310 7267 7269 7278 7198 7260 7224 8470 5199 7177 7220 9241 8310 7263 7290 7260 8248 8122 8270 8058 8140 2740 8409 7840 9593 9592 7371 7242 7251 8472 4579 7288 8489 7291 7292 7310 4 - 90 Version 1.0 Claims Submission Resource Manual for Physicians Physiotherapy Diagnosis Pain Plantar Fascitis Pelvis Inflammatory Disease/ Salpingitis PVD Rheumatism (muscle) Sacro-iliac Strain - Hip Scoliosis (unspecified) Spondylolisthese Strained Description Arch Back (posterial) Back (low) Neck Ankle Elbow Hip Knee and Leg Metacarpal Shoulder Shin Splints Stiff Neck Synovitis Temporomandibular Strain/Sprain Tendinitis Tennis Elbow Thoracic Strain Torn Rotator Cuff Torticollis Trapezius Sprain Whiplash Injury February 2014 Code 7295 7245 7242 7231 7287 6142 4439 7290 8439 7379 7561 8450 8419 8439 8449 8421 8409 8449 7235 7270 8481 7269 7263 8471 8404 8470 8408 8470 4 - 91 Version 1.0 Claims Submission Resource Manual for Physicians 4.14 Questions and Answers What is the monthly cut-off for claims submission and when will I receive payment? Claims submissions received by the 18th of the month will be processed for payment by the 15th of the following month. When the submission cut-off date (18th) falls on a weekend or holiday, the deadline will be extended to the next business day. Claims received after the 18th of the month will be processed prior to month end if time and volumes permit. My software program includes a field for “Manual Review Indicator”. What is it and when would I use it? For most claims, this field would be blank; however, if the claim requires special consideration (e.g., two identical services billed same day), a Y indicator should be entered in this field. If Y is used, the claim will be flagged for internal manual reviewed and adjudication. Supporting documentation must be sent to the ministry so that it can be matched to the claim submission. The “Claims Flagged for Manual Review” form (2404-84) indicates the information that is required for claims submitted with a Y indicator. This information is to be included in the supporting documentation as well. The form and supporting documentation should be faxed to your claims processing office: http://www.health.gov.on.ca/en/pro/programs/ohip/claimsoffice/default.aspx When claims are submitted, how do I get notified of submission errors? Claim errors are listed on your Claims Error Report which will be sent to you within 48 hours after the file submission. Errors reported must be corrected and resubmitted in order for payment to be made. Error reports should be retained in order to track claims that may not appear on the next RA. When is a claim considered stale dated? Claims must be submitted within six months of the service date. Claims submitted more than six months after the service has been rendered will not be accepted for payment unless there are extenuating circumstances as defined by ministry policy. How do I inquire about a claim that has been overpaid/underpaid? Inquiries regarding overpayments or underpayments should be made within one month of the RA on which the payment appears and must be made and resolved within six months from the service date in order for any payment adjustment to occur. Inquiries should be submitted to your claims processing office on a “Remittance Advice Inquiry” form (0918-84). February 2014 4 - 92 Version 1.0 Claims Submission Resource Manual for Physicians The above forms are available online at: http://www.health.gov.on.ca/en/pro/forms/ohip_fm.aspx February 2014 4 - 93 Version 1.0
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