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Pregnancy-Related Claims May Erroneously Deny with ICD-10 Diagnosis Codes

January 20, 2016

The Department of Health Care Services (DHCS) has identified a claims processing issue that may cause claims to erroneously deny when billed with CPT-4 code 59025 (fetal non-stress test) or HCPCS code Z1030 (non-oxytocin fetal stress test) and certain ICD-10 diagnosis codes.

The Pregnancy: Early Care and Diagnostic Services section of the Part 2 provider manual listed the incorrect ICD-10-CM code range of O09.00 – O9A.53 for billing with CPT-4 code 59025 or HCPCS code Z1030. The following corrected ICD-10 diagnosis code ranges are allowable diagnoses for billing CPT-4 code 59025 or HCPCS code Z1030, effective for claims with dates of service on or after October 1, 2015.

O00.0 – O16.9 O77.0 – O77.9 O98.611 – O98.619
O21.0 – O21.9 O88.011 – O88.019 O98.711 – O98.719
O23.00 – O26.62 O88.211 – O88.219 O98.811 – O98.819
O26.821 – O26.849 O88.311 – O88.319 O99.011 – O99.119
O26.872 – O26.899 O90.5 – O90.81 O99.280 – O99.333
O28.0 – O31.8X0 O98.0 – O98.019 O99.340 – O99.353
O32.0XX0 – O41.1499 O98.111 – O98.119 O99.411 – O99.419
O42.00 – O43.119 O98.211 – O98.219 O99.511 – O99.830
O43.191 – O43.210 O98.311 – O98.319 O99.840 – O99.843
O43.810 – O60.03 O98.411 – O98.419 O9A.111 – O9A.53
O67.0 – O68 O98.511 – O98.519  

In addition, effective for dates of service on or after October 1, 2015, CPT-4 code 59025 is not reimbursable with ICD-10 diagnosis code O76 (abnormality in fetal heart rate and rhythm complicating labor and delivery) for a billing frequency greater than 10 times in 9 months. Updated manual pages reflecting these changes will be released with a future Medi-Cal Update.

DHCS will alert providers when the issue is resolved. Providers should continue to submit claims in a timely manner. Affected claims will be reprocessed via an Erroneous Payment Correction (EPC). Providers are encouraged to check the Medi-Cal website regularly for updates regarding this issue.