Tennessee: Inappropriate Primary/Principle Diagnosis Policy, Facility Update

It was previously communicated Oct. 1, 2020, on the Community Plan Portal, that the UnitedHealthcare Community Plan is implementing a new Inappropriate Primary Diagnosis Policy, Facility, for facility claims. Implementation of this new facility policy has been delayed until on or after date of process June 1, 2021:

  • This new policy will deny claims where an inappropriate diagnosis is in box 67 on a UB-04 claim form or its electronic equivalent
  • ICD-10-CM specifies when a diagnosis code should never be listed as the primary diagnosis on an outpatient claim
  • When a code on the Inappropriate Primary Diagnosis list is listed as the primary diagnosis on the claim form, the claim will be denied. However, care providers can resubmit corrected claims with the correct Dx coding.

The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Official Guidelines for Coding and Reporting, developed through a collaboration of the Centers for Medicare & Medicaid Services (CMS), the National Center for Health Statistics (NCHS) and the Department of Health and Human Services (HHS), provides clear direction on the coding and sequencing of diagnosis codes. Using the ICD-10-CM Official Guidelines for Coding and Reporting, this policy identifies diagnosis codes that should never be billed as primary on an outpatient hospital (UB-04) claim form or its electronic equivalent.

You can find these updates at Reimbursement Policies for Community Plan.

We’re here to help

If you have questions about policy updates, please contact your Network Account Manager or Provider Advocate. Thank you.