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Kareo Help Center

Why can’t 12 diagnosis codes be added to a procedure?

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Why can't 12 diagnosis codes be billed for one procedure?

The 5010 and CMS-1500 forms were modified to support up to 12 diagnosis codes per claim (while maintaining the limit to four diagnosis pointers) as a means to reduce paper and electronic claims from splitting. The change was never intended to increase the number of diagnosis codes per line item. 

Prior to this modification, the 4010 supported up to eight unique diagnosis codes per claim, and the older CMS-1500 supported four. Any codes exceeding those limits would split the 837 into two claims and paper claims into three. Increasing the total of supported diagnosis codes on the claim format not only reduced the amount of claims splitting, it also translated into substantial administrative and cost savings for both practices and payers.

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Why does a claim allow 12 diagnosis codes if a line of service/procedure code can only support up to four?

There are times when having more than four diagnosis codes on a claim is vital to documenting the full extent of a patient’s illnesses or injuries. While there are 12 slots for diagnoses, only a maximum of four will ever be allowed for a single procedure. The additional diagnosis slots are intended for multiple lines of service/procedure codes to capture up to four unique diagnosis codes each.

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Will Kareo be updated to allow more than four diagnosis codes for a single line of service?  

At this time, Kareo will continue to follow the official 837 specification published by CMS that supports four diagnoses per procedure line. Learn an alternative method for submitting a claim with additional diagnosis codes here.

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What can I do if I need to report more than four diagnosis codes for a single line of service?

Some payers recognize the need to include more than four diagnosis codes for a procedure and provide alternate reporting methods. A commonly used alternate method for submitting claims is described in our help article. Note that this method may not apply to all payers, so it’s important to contact the individual payer in advance to verify that this method is accepted.