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Diagnosis Codes

An International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code must be used to identify each patient's diagnosis or nature of illness or injury. A written diagnosis is not required when the code is given. Diagnosis codes are very important in making benefit determinations. They are used to evaluate whether or not services are medically necessary, if a condition is pre-existing, if Worker's Compensation is applicable, and for screening medical emergencies. Providers should use the most recent version of the ICD-9-CM coding book and should code to the highest level of specificity for the diagnosis.

It is critical that Blue Cross and Blue Shield of Alabama receive complete and accurate coding data to properly indicate our members' health status. This information drives the development of care management strategies and identifies patients most in need of resources. It also conveys the complexity of our patients' health or "risk," which will impact future premium rates and provider incentive programs.

ICD-10 is a coding system consisting of diagnosis and inpatient procedure codes that will replace the current ICD-9 system. The government is mandating the implementation of ICD-10 to be effective with dates of service no earlier than October 1, 2015. Once this is effective, Blue Cross will require all claims, both electronic and paper, to include ICD-10 codes for diagnosis and inpatient procedure codes.

Last Updated June 2015