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August 15, 2019

Dual Diagnosis Requirements – Claims Submission

Medical Review has noticed an increase in the number of claims submitted for services that require a dual diagnosis based on a Local Coverage Determination (LCD) where both diagnosis requirements are not included on the initial claim submission. We have noticed that when the initial claim is processed providers are getting denials and then requesting a reopening of the claim to add the additional diagnosis or filing for a redetermination. In determining the code or codes appended to a claim, the medical records must always support the codes submitted.

To ensure your claims are processed in an efficient manner when billing for a service /procedure that has a LCD, the LCD should be reviewed to determine if dual diagnosis are required or if a single diagnosis is sufficient. In those cases where a dual diagnosis is required the ICD-10 coding section will be marked with an asterisk.

To be compliant with the 21st Century Cures Act, CGS will be migrating all coding from the LCD to a coding and billing article linked to the related LCD.

CGS hopes this will be easier for our providers to recognize the need for the dual diagnosis requirement in our LCD's and have their claims processed upon initial submission to avoid delays in payment.

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