Issue #12-04

Medicaid claims for SSHSP services rendered on or after September 1, 2012 must include a valid diagnosis code.

The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is a set of codes used by health care providers to indicate diagnosis for all patient (student) encounters. ICD-9-CM codes are composed of three-, four-, and five-digit numeric and alphanumeric codes. Each code represents a specific disease, condition, or description of a symptom of the student.

In addition to compliance with the Health Insurance Portability and Accountability Act (HIPAA) 5010 transaction requirements, the inclusion of an appropriate diagnosis code on SSHSP claims will create a source of data that can be used:

• to show why services were rendered;
• for resource allocation purposes, such as appropriate staffing and scheduling;
• to track utilization of services.

Written orders and written referrals for SSHSP evaluations and services must include the student’s diagnosis or the reason/need for a medically necessary service. The diagnosis on the written order/referral is the main condition or symptom of the student. This main condition or symptom is the reason the service is being provided. The diagnosis on the written order/referral should be included on each Medicaid claim submitted via eMedNY for the ordered/referred SSHSP service. In cases where there are multiple diagnoses, decisions regarding which diagnosis is appropriate to bill under for a specific service should be made by clinicians (i.e., the ordering or attending provider.)

Each Medicaid claim for an SSHSP service rendered on or after September 1, 2012 must include the diagnosis code that represents the reason the service was rendered.

School districts, counties, and §4201 schools contracting with third party billing vendors, or utilizing billing software programs, are responsible for ensuring that the vendor or software is able to capture, process, and/or transmit the applicable ICD-9-CM codes for each SSHSP claim to the Central New York Regional Information Center (CNYRIC), the statewide central billing agency.

Please see the questions and answers about ICD-9-CM codes and the use of diagnosis codes on SSHSP Medicaid claims that follow for additional information.

1. Who can assign a diagnosis?

Under the SSHSP, licensed and currently registered and/or certified (as required) practitioners who may diagnose medical conditions, illnesses, and diseases within their scope of practice, include:

• Physicians and physician assistants,
• Nurse practitioners,
• Speech-language pathologists,
• Psychologists,
• Psychiatrists,
• Audiologist.
2. Where can the ICD-9-CM code set be found?

   The code set is available from CMS online.

3. Where does the diagnosis code for the claim come from?

The student’s diagnosis and/or reason/need for a medically necessary service is required on written orders/referrals for SSHSP services. The SSHSP Medicaid claim submitted via eMedNY must contain an ICD-9-CM code that describes the main condition or symptom of the student. In most cases the diagnosis supplied on the written order/referral by the ordering practitioner is the most appropriate diagnosis to include on Medicaid claims for those services.

In the case of psychological counseling services a specific diagnosis code might not be included on written order/referral when the person recommending psychological counseling is not a licensed medical professional. However, the written order/referral will include the reason/need for the referral. The evaluating clinician can assign a diagnosis based on the results of their evaluation of the student.

In the case of special transportation services the school districts, counties, and §4201 schools may use the diagnosis from a written order/referral for another SSHSP service the student is receiving or 799.9 (other unknown and unspecified cause of morbidity or mortality) on the SSHSP Medicaid claims submitted via eMedNY.

4. What if the written order/referral has more than one diagnosis on it, how does the provider decide which one to use on the SSHSP Medicaid claim?

If the written order/referral for the SSHSP service has more than one diagnosis included, school districts, counties, and §4201 schools may include all applicable diagnoses on the electronic SSHSP Medicaid claim.

5. A written order is on file for physical therapy and another for occupational therapy, each has a different diagnosis included. Which diagnosis should be used on the SSHSP Medicaid claims?

To the extent possible, the diagnosis on the written order/referral should be used on the SSHSP Medicaid claims for that specific service. This means that the SSHSP Medicaid claims for physical therapy should include the diagnosis from the written order for the physical therapy services and the claims for occupational therapy should include the diagnosis from the written order for occupational therapy services.

As previously noted, decisions regarding the appropriate diagnosis code(s) should be made by clinicians (i.e., ordering or attending).

6. Who can ‘translate’ the diagnosis or the reason/need for an ordered/referred service into a valid ICD-9-CM code?

If the written order/referral does not contain the actual numeric or alphanumeric ICD-9-CM code, the diagnosis will have to be translated into the appropriate numeric or alphanumeric code so that it can be submitted on the electronic Medicaid claim(s).

School districts, counties, and §4201 schools have several options to obtain the necessary information. These sources may include, but are not limited to: requesting that the ordering practitioner provide the numeric or alphanumeric code, requesting that the attending practitioner ‘translate’ the words to an appropriate ICD-9-CM code, consulting coding books and resources, consulting coding professionals with adequate experience, or contacting physicians or other health professionals.

7. What format should the ICD-9-CM codes be in (how many positions — 3, 4, or 5) on the SSHSP Medicaid claims?

Providers must use the most specific code available. A provider would assign:

• a three-digit code (category codes) if there are no four-digit codes within the category, or
• a four-digit code (subcategory codes) if there are no five-digit codes for that category, or
• a five-digit code (fifth-digit subclassification codes) for those categories where they are available.

For example:

314 Hyperkinetic syndrome of childhood
314.0 Attention deficit disorder
314.00 Without mention of hyperactivity
314.01 With hyperactivity
314.1 Hyperkinesis with developmental delay
314.2 Hyperkinetic conduct disorder
314.8 Other specified manifestations of hyperkinetic syndrome
314.9 Unspecified hyperkinetic syndrome

The provider would not be able to assign ICD-9-CM code 314 (Hyperkinetic syndrome of childhood) or 314.0 (Attention deficit disorder) because there are five-digit codes within the category. The provider would be able to assign the following codes because they represent the highest level of specificity within that category: 314.00, 314.01, 314.1, 314.2, 314.8, or 314.9.

Please note: Preparations are underway for ICD-10-CM coding, which will bring a greater level of specificity. Clinicians can keep informed about changes through the CMS website.