4 CLAIMS SUBMISSION

Transcription

4 CLAIMS SUBMISSION

CLAIMS SUBMISSION
4
4.1 OVERVIEW .................................................................................................. 4-3
4.2 METHOD OF SUBMITTING CLAIMS .......................................................... 4-3
Medical Claims Electronic Data Transfer ..................................................... 4-3
Electronic Data Transfer (EDT) .................................................................... 4-4
4.3 PROCESS TO SUBMIT CLAIMS ................................................................. 4-5
4.4 SUBMISSION OF CLAIMS .......................................................................... 4-5
HCP Claim ................................................................................................... 4-5
WSIB Claim .................................................................................................. 4-6
RMB Claim ................................................................................................... 4-6
Patient Information ....................................................................................... 4-7
Coding Requirements .................................................................................. 4-8
Cut-Off Date for Claims Submission ............................................................ 4-8
Resubmission of Unpaid Claims .................................................................. 4-9
Claims Requiring Documentation ................................................................. 4-9
Claims Submission
Resource Manual for Physicians
4.5 REPORTS .................................................................................................... 4-9
File Reject Message ..................................................................................... 4-9
Batch Edit Report ......................................................................................... 4-9
Claims Error Report ................................................................................... 4-10
Split Claims Error Report............................................................................ 4-11
Remittance Advice Report (RA) ................................................................. 4-11
Group RA Split/Extract ............................................................................... 4-11
OBEC Response File ................................................................................. 4-11
Governance Reports .................................................................................. 4-12
Primary Care Reports ................................................................................ 4-12
Enrolment/Consent Outside Use Report .................................................... 4-12
Enrolment/Consent Patient Summary Report ............................................ 4-12
4.6 RECONCILIATION AND PAYMENT .......................................................... 4-12
4.7 INQUIRIES ................................................................................................. 4-13
4.8 PROVINCE/TERRITORY CODES ............................................................. 4-14
4.9 ERROR CODES ........................................................................................ 4-15
4.10 ERROR REPORT MESSAGES ................................................................. 4-22
4.11 EXPLANATORY CODES ........................................................................... 4-23
4.12 SPECIALTY CODES .................................................................................. 4-29
Physician .................................................................................................... 4-29
Dental ......................................................................................................... 4-30
Practitioner ................................................................................................. 4-30
Other .......................................................................................................... 4-30
4.13 DIAGNOSTIC CODES ............................................................................... 4-32
4.14 QUESTIONS AND ANSWERS .................................................................. 4-92
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4.
CLAIMS SUBMISSION
4.1
Overview
This section provides an overview of the claims submission process, including:
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4.2
method of submitting claims
process to submit claims
submission of claims
reports
reconciliation and payment
inquiries
Method of Submitting Claims
All claims must be submitted through electronic data transfer (EDT) in accordance
with Regulation 552, Section 38.3 of the Health Insurance Act (HIA). The ministry
offers two EDT services: the web-enabled Medical Claims Electronic Data Transfer
(MC EDT) and the Electronic Data Transfer (EDT).
Medical Claims Electronic Data Transfer
The MC EDT is a secure web-enabled service that offers a:
• simple user interface (web page) with basic upload and download functions
using an internet connection; and
• a web service for complete automation and integration with Electronic Medical
Record (EMR)/Clinic Management System (CMS) software or billing software
systems.
The web page was implemented in October 2012 and the web service will be
available in early 2013.
The web page is not intended for use with automated programs or scripts. The MC
EDT web page is suitable for those with a low number of daily file uploads. File
uploads and downloads are a manual process and cannot be scripted or integrated
with a systems interface.
Users of the web service will require third party software/vendor to develop a fully
automated system to submit and receive files. The MC EDT technical
specifications for the web service is located on the ministry website at:
http://www.health.gov.on.ca/english/providers/pub/pub_menus/pub_ohip.html
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Some of the key benefits of the MC EDT service include:
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Secure user authentication;
Ability to designate access to administrative staff, third party agents or other
health care providers, to act on your behalf for the submission and/or
reconciliation of claim files;
Additional electronic reports.
The MC EDT service is available 24 hours a day, seven days a week with the
exception of weekly scheduled system maintenance on Sunday mornings between
the hours of 1:00 am and 5:00 am and Wednesday mornings between the hours of
5:00 am to 8:00 am.
The MC EDT service currently supports the following file types:
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Medical Claims
Stale Dated Claims
Overnight Batch Eligibility Checking (OBEC)
For further information on MC EDT, refer to the MC EDT Reference Manual located
at:
http://www.health.gov.on.ca/english/providers/pub/pub_menus/pub_ohip.html
Electronic Data Transfer (EDT)
The EDT service is a vehicle for the electronic transmission of files from an
authorized EDT user’s mailbox to the ministry’s mainframe computer via the
Government of Ontario Network (GONet). The EDT service will only be available
until early 2014 at which time it will be phased out. A computer with
telecommunication software is required to access the EDT service and billing
software is also required. Telecommunication service and associated costs/terms
are the responsibility of each EDT user. You should contact a software vendor as
there are specific technical requirements for the EDT service.
Before you begin submitting claims, you must:
•
complete the “Application for GONet Electronic Data Transfer (EDT) Service”
form (3274-84) and the “EDT Undertaking and Acknowledgement” form (327984). These forms are available online at:
http://www.health.gov.on.ca/en/pro/forms/ohip_fm.aspx
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send the completed forms to the ministry at EDT Registration, P.O. Box 68,
Kingston, ON K7L 5K1
The ministry will send you an EDT User ID and temporary password when your
forms have been processed.
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The EDT Reference Manual has been prepared to assist you with registering for
EDT.
It contains the following information:
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Benefits of EDT
Claims processing and payment scheduling
How to register for EDT
List and explanation of technical requirements
Questions to ask your software vendor
Glossary of terminology
The EDT Reference Manual and further information on the EDT service is located
on the ministry website at:
http://www.health.gov.on.ca/english/providers/pub/ohip/edtguide/edt_mn.html
4.3
Process to Submit Claims
Claim files must be submitted in a specific file format as outlined in the Technical
Specifications-Interface to Health Care Systems manual.
You should contact a software vendor to determine the most appropriate hardware
and billing software that would meet your needs based on your business practices
and technical capabilities. All hardware and software must conform to the
specifications as contained in the Technical Specifications-Interface to Health Care
Systems manual.
4.4
Submission of Claims
There are three types of claims a physician will submit:
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Health (HCP)
Workplace Safety Insurance Board (WCB)
Reciprocal Medical Billing (RMB)
HCP Claim
Health claims are claims for services rendered by physicians or private medical
labs to a patient with Ontario health insurance coverage.
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Payment program “HCP”
Payee - “P” for pay provider
Payee - “S” for pay patient
Note: Payee is dependent on whether you opted in or opted out when you
registered.
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WSIB Claim
Workplace Safety and Insurance Board (WSIB) (formerly Workers’ Compensation
Board (WCB)) claims are for services rendered to patients with Ontario health
insurance coverage who have work related injuries.
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Payment program is WCB
Payee is “P” for pay provider
If the patient is assessed for a non-WSIB related problem during a WSIB visit
(minor assessment only), A008A (Mini Assessment) may be payable. Refer to
the Schedule of Benefits, sections General Preamble and Consultations and
Visits
A008A cannot be billed on the same claim as the WSIB service. It must be billed
on a separate HCP claim. A008A can be billed only when the WSIB claim is for
A001A
If the physician bills any service on a WSIB claim other than a minor or partial
assessment, no other assessment can be submitted as an HCP claim.
Note: Other than the payment program, the information required to bill is the same
as for HCP claims.
The following services are excluded from WSIB submissions to the ministry:
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Service codes prefixed by “T” or “V”
Lab services provided by private medical laboratory facilities
Services provided by hospital diagnostic departments
Services rendered to patients registered in other Canadian provincial plans
Services rendered by out-of-province physicians
Fee schedule codes: A008, K018, K021, K051, K053, K061, P004, P006
Charges for completion of form, such as M640 (must be billed directly to WSIB)
Services provided by OPTED-OUT health care providers
RMB Claim
Reciprocal Medical Billing claims are used to bill for services rendered by
physicians or private medical labs to a patient insured under another Canadian
provincial health coverage plan, excluding Quebec.
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Payment program - RMB
Payee - P for pay provider
Note: Except for the section on patient information all other areas are identical to
those on the regular HCP claim.
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Patient Information
Province
Two letter code representing the province of the
patient’s registration
Registration Number
Assigned to the patient in his or her province of
residence (may be up to 12 characters without any
spaces or special characters)
Date of Birth
YYYYMMDD format (e.g., 19491225)
Patient’s Surname
Up to 13 characters of the patient’s last name
Payment Program
Must be RMB
Payee
Must be P for pay provider
Patient’s First Name
Up to six characters of the patient’s first name
Sex
1 (male) or 2 (female)
Participation in the Reciprocal Medical Billing System (RMBS) is voluntary.
Physicians who do not submit through the RMBS and bill the ministry directly must
complete and submit the standard “Out of Province Claim for Physician Services”
form (0000-80) available online at:
Form is also used for claims for residents of Quebec and for RMB excluded
services that are OHIP benefits.
The following services are excluded from RMB (but are not necessarily OHIP
benefits) and should be billed directly to the non-resident patient:
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Surgery for alteration of appearance (cosmetic surgery)
Sex reassignment surgery
Surgery for reversal of sterilization
Therapeutic abortion
Routine periodic health examinations including routine eye examinations
In-vitro fertilization, artificial insemination
Lithotripsy for gall bladder stones
Treatment of port wine stains on other than the face or neck, regardless of the
mode of treatment
Acupuncture, acupressure, transcutaneous electro-nerve stimulation (TENS),
moxibustion, biofeedback, hypnotherapy
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Services to persons covered by other agencies (i.e., RCMP, Armed Forces,
Workplace Safety and Insurance Board, Department of Veterans’ Affairs,
Correctional Services of Canada [Federal penitentiaries])
Services requested by a third party
Team conference(s)
Genetic screening and other genetic investigation, including DNA probes
Procedures still in the experimental/developmental phase
Anaesthetic services and surgical assistant services associated with all of the
above
Services required by the Ministry of Community and Social Services and the
Ministry of Attorney General or the Solicitor General
Note: The patient may be eligible for direct reimbursement by his or her own
provincial plan.
Coding Requirements
Fee Schedule Codes are located in the ministry Schedule of Benefits for Physician
Services. In addition, the following information will assist with the submission of
claims:
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Diagnostic Codes
Services Requiring Diagnostic Codes
Cut-Off Date for Claims Submission
The ministry operates on a monthly billing cycle. Claims received by the 18th of the
month will typically be processed for payment by the 15th of the following month.
When the 18th falls on a weekend or holiday, the deadline will be extended to the
next business day. Claims received after the 18th of the month will be processed
prior to month end if time and volumes permit.
Claims must contain complete, valid and accurate information in order to be
processed on time. Claims requiring internal review by ministry staff may have
payment delayed.
The ministry recommends daily or weekly submissions of claims to ensure timely
adjudication of claims files and to aid in the subsequent reconciliation of rejected
claims.
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Resubmission of Unpaid Claims
In accordance with regulation under the HIA, all claims must be submitted within six
months of the date of service. This includes original claims, resubmitted claims and
Remittance Advice (RA) payment inquiries. Claims submitted more than six months
following the date of service are termed “stale dated” claims.
Claims Requiring Documentation
The manual review indicator is a field in your medical claims billing software which
allows you to inform the ministry that special attention is required to process a
specific claim.
Supporting documentation should be faxed to your claims processing office when
the claim is submitted:
http://www.health.gov.on.ca/en/pro/programs/ohip/claimsoffice/default.aspx
Supporting documentation may include an operative report, or a “Claims Flagged
for Manual Review” form (2404-84). The reasons for submitting this form as
supporting documentation are listed on the form.
A “Request for Approval of Payment for Proposed Surgery” form (0691-84) is
another supporting document; however, it is to be submitted to your claims
processing office prior to the service being rendered.
These forms are available at
4.5
Reports
The following reports are sent electronically from the ministry. Only reports
applicable to your practice will be sent to you. All reports must be retrieved
(downloaded) for review or appropriate action.
File Reject Message
A File Reject Message notifies you if the ministry has rejected an entire claims file.
This report is usually sent within a few hours of the ministry receiving your claims
submission.
Batch Edit Report
A Batch Edit Report notifies you of the acceptance or rejection of claims batches.
This report is usually sent within 24 hours of the ministry receiving your claims
submission. If claims are uploaded on a weekend, holiday or at month end, the
Batch Edit Report is delivered on the next claims processing day.
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Claims Error Report
Claims submitted may be rejected for a variety of error conditions. Each file
submission processed by the ministry will generate an Error Report (if applicable),
therefore, several error reports may be received throughout the month based on
the frequency of claims submissions. Claims rejected to an Error Report are
automatically deleted from the payment stream. Rejected claims must be corrected
and resubmitted to be processed for payment.
A Claims Error Report provides a list of rejected claims and the appropriate error
codes or error report message for each claim. Error codes may be reported at the
header level of a claim and/or at the item level. Rejected claims may have more
than one error code or error report message assigned (refer to section – Error
Codes or Error Report Messages for further detailed explanation of the possible
error codes).
The Error Code is a three-character alpha/numeric code. The first character is an
alpha and denotes the type of reject as follows:
V
A
E
R
Validity Error (applies to HCP/WCB/RMB payment programs)
Assessment Error (applies to HCP/WCB/RMB payment programs)
Eligibility Error (applies to HCP/WCB/RMB payment programs)
Reciprocal Medical Billing (RMB) Specific Errors
A rejected claims item may be internally re-routed to the Error Report by the
ministry and will include an error report message. The error report message is
generated to provide more detailed information as to why the claim is being
returned. Error report messages appear directly below the related claim item (refer
to section – Error Report Messages).
Rejected claims shown on the Error Reports are returned during the processing
month. The corrected information should be resubmitted immediately. If the
resubmitted information is received prior to the 18th of the same month, the claim
can be processed for payment in the same billing cycle. Claims must be
resubmitted within six months of the date of service to avoid being rejected as a
stale dated claim.
Claims Error Reports should be retained on file in your office to assist in monthly
payment reconciliations. If claims are not approved for payment on your monthly
Remittance Advice Report (RA), then check your Error Report for that month to
determine if the claim was rejected and needs to be submitted again.
A Claims Error Report is usually sent within 48 hours of claims file submission. If
claims are uploaded on a weekend, holiday or at month end, the Error Report is
delivered on the next claims processing day.
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Split Claims Error Report
The Split Error Report is only available to physicians affiliated with a primary care
group.
This report summarizes an individual physician’s rejected claims that were
submitted under the group number. A list of rejected claims and the appropriate
error codes for each claim will appear on the report (refer to section – Error Codes).
Remittance Advice Report (RA)
An RA is a monthly statement of approved claims. You will receive your RA
between the 5th and 7th of the month following the successful submission and
processing of your claims.
Your RA is issued before you receive your payment on the 15th business day of
each month.
Group RA Split/Extract
The group RA Split/Extract is only available to individual physicians within a Family
Health Network (FHN) for reconciliation of their own claims.
The FHN primary care groups operate over a wide area of separate physical
locations and every physician in a FHN may have a different billing package and
submit claims from individual locations. The RA Split/Extract contains a FHN
physician’s own claim details only.
OBEC Response File
OBEC is a Health Card Validation (HCV) method that enables health care
professionals to verify the eligibility of a patient’s health number/version code
before a health service is provided. A formatted file of health numbers/version
codes can be sent to the ministry for processing and eligibility is verified against the
ministry’s database based on the date the file is submitted.
OBEC files received by the ministry by 4:00 pm are processed overnight and the
response file will be sent to your MC EDT account by 7:00 am the following
morning.
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Governance Reports
Governance Reports are only sent to groups that provide specialty services in a
hospital or an academic health sciences centre within specific communities. The
following reports are generated monthly and sent to the MC EDT account for the
governance at time of registration with the ministry.
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Academic Health Science Centre (AHSC) Governance Reports
Northern Specialist Alternate Payment Program Governance Reports
Primary Care Reports
The following enrolment/consent reports are only sent to primary care physicians.
Enrolment/Consent Outside Use Report
Outside Use is a core service that is provided to enrolled patients by any family
physician who is not affiliated with the patient’s primary care group. The report
includes outside use details for each physician within a specific primary care group
to assist in the calculation of their Access Bonus payment.
Enrolment/Consent Patient Summary Report
This report is a summary of patient enrolment activity to date. The report includes
total number of members, breaks down total numbers into member status (e.g.
assigned, enrolled, pre-members) and unconfirmed total.
4.6
Reconciliation and Payment
Your RA may contain codes that indicate when a service has been reduced or
disallowed because of medical rules which control the payment of claims (refer to
section – Explanatory Codes).
Inquiries on your RA should be submitted within one month and no later than six
months from the date of service.
Information updates will be transmitted via the message facility of the monthly RA.
It is important that your reconciliation software allows you to read information
displayed in the RA message facility. Please read all communications to ensure you
are up-to-date on topics relevant to your practice. Copies of communications should
be kept for reference.
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4.7
Inquiries
Inquiries regarding overpayments or underpayments should be made within one
month of the RA on which the payment appears and must be made and resolved
within six months from the service date for any adjustment to payments to occur.
Inquiries should be submitted to your claims processing office on a “Remittance
Advice Inquiry” form (0918-84) which is available online at:
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4.8
Province/Territory Codes
PROVINCE/TERRITORY
PROVINCE
CODE
FORMAT
ALBERTA
• Prior to June 1/94, 11
numerics
AB
9 numerics - individual
registration
(effective June 1/94)
BRITISH COLUMBIA
BC
registration
(effective Jan. 1/91)
MANITOBA
• Prior to Apr 1/05, 6 numerics
MB
9 numerics – individual
registration
(effective Apr. 1/05)
NEWFOUNDLAND/LABRADOR
NL
registration
NEW BRUNSWICK
NB
registration
NORTHWEST TERRITORIES
NT
NOVA SCOTIA
• Prior to Jan. 1/94, 11
numerics (Family Based)
NS
8 characters - individual
registration
One alpha (N, D, M or T and 7
numerics)
registration
(effective Jan. 1/94)
PRINCE EDWARD ISLAND
PE
9 numerics (SIN) - individual
registration
SASKATCHEWAN
SK
registration
(effective April 1/91)
TERRITORY OF NUNAVUT
NU
registration
(effective April 1/99)
YUKON
YT
registration
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4.9
Error Codes
A2A
A2B
A3E
A3F
A3L
A34
A4D
AC1
AC4
AD9
AH5
AH8
AMR
EF1
EF2
EF3
EF4
EF5
EF7
EF8
EF9
EH1
EH2
EH4
EH5
Patient is underage or overage for this service code
This service is not normally performed for this sex. Please check your
records.
No such service code for date of service
No fee exists for this service code on this date of service
Other New Pt Fee Already Pd
Multiple duplicate claims
Invalid specialty for this service code
Maximum reached – resubmit alternate fsc
A valid referring/requisitioning health care provider number must be present
for this service code.
Referring number is 722900-744292 (Nurse Practitioner) and
FSC are not any of the following:
- Laboratory Services (L***)
- Cardiology codes G310, G313, G700
- Physiotherapy Code
- Xray - X codes
- Ultra Sound Codes - J codes
Premium not allowed alone
Admit date mismatch
Hospital and/or Admission date is missing or invalid. - Invalid Adm Dte/Hosp
No
Minimum service requirements have not been met.
IHF number not approved for billing on the date specified
IHF not licensed or grandfathered to bill FSC on the date specified
Insured services are excluded from IHF billings
Provider is not approved to bill IHF fee on date specified
IHF practitioner 991000 is not allowed to bill insured services
Referring physician number is required for the IHF fee billed
‘I’ service codes are exclusive to IHFs
Mobile site number required
Srv. Date <Elig. Eff. Date
Mismatched Version Code
Srv. Date > Elig. End Date
Srv. Dt. Not in Elig. Period
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ENP
EPA
EPC
EPF
EPP
EPS
EP1
EP2
EP3
EP4
EP5
EQ1
EQ2
EQ3
Invalid FSC for NP
Network billing not approved
Patient not rostered/rostered to another Network
Enrlmt Date Mismatch
Incorrect Code for Eligibility (Ontario Works/Ontario Disability Support
Program)
Patient Not Elig for Prog
Enrlmt Trans Not Allowed
Not for Enrol/Re Enrol
Check Srv Dte / Enrol Dte
Enrolmnt Restriction
Incorrect FSC for Grp Typ
Practitioner not registered with OHIP - Clinic/Dr Not on File
Specialty code is inactive or not registered on date of service
Health care provider is registered as OPTED-IN for date of service – claim
submitted as Pay Patient
EQ4
Health care provider is registered as OPTED-OUT for date of service – claim
submitted as Pay Provider
EQ5
EQ6
Lab inactive for service date
Referring/requisitioning health care provider number is not registered with
the Ministry of Health
EQ9
EQB
Lab No. not on File
Solo health care provider number is not actively registered with the Ministry
of Health on this date of service
EQC
EQD
Practitioner number is Midwife (700000 - 722899) referral only
Claims submitted by Chiropractors using their CSN
Group number is not registered with the Ministry of Health.
Group number is not actively registered with the Ministry of Health on this
date of service
EQE
Health care provider is not registered with the Ministry of Health as an
affiliate of this group on date of service
EQF
Health care provider is not actively registered with the Ministry of Health as
an affiliate of this group on date of service
EQG
EQJ
Referring laboratory is not registered with the Ministry of Health
New Graduate bills New Patient fee (q013) or Physician (not a new
graduate) bills new Graduate – New Patient fee (Q033) - Pract. Not Elig. On
S/D
A100 billed with a specialty code other than 00. - MNI Does not Meet Criteria
EQK
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EQL
A100 billed with a speciality code other than 00 or billed by provider with any
EDAFA group number. - Phy Not Eligible to Claim
EQM
EQN
EQS
ERF
ESD
ESF
Not Registered for Use
Reg Usage Err on S/D
Provider does not have a sub-specialty of PSY. - Pract Criteria Not Met
Referring physician number is currently ineligible for referrals
APP group affiliation on service date
A non-encounter service claim submitted by a physician not eligible to bill
FSC
If a claim is submitted by a Mental Health Sessional Group for a code other
than K400A, reject the claim to the error report. - Not Elig. For Blank HN
ESH
ESN
If health number is on the claim for K400A- No HN required for FSC. Invalid
Blank HN Claim
ET1
The telemedicine billing is submitted by a physician who is not registered as
a Telemedicine physician. - Not Reg for Telemedicine
ET4
The telemedicine billing does not include a telemedicine premium code
(B100, B101, B102, B200, B201, B202) - Telemed Fee code missing
ET5
The telemedicine billing is submitted with a telemedicine premium/tracking
code but the SLI code is not ‘OTN’ or is not present. - Telemed SLI
Missing/Invld
Not on Health Care Connect (HCC) database - Not Eligible
On HCC database but not Complex-Vulnerable
On HCC database but not in 'referred to' status
Patient enrolled to billing physician but later than 3 months from the “referred
to” date on Health Care Connect database - Enrolment after 3 Months
HCC
HCE
PAA
To ensure the smoking cessation initial discussion fee (E079) has been paid
within 365 days prior to the smoking cessation counseling fee (Q042) or the
smoking cessation follow up fee (K039) - No Initial Fee Prev. Pd.
PA1
Physician Assistant (PA) Pilot claim submissions may contain one or more
PA Tracking FSC’s but other OHIP insured service FSCs are not allowed on
the same claim. - Invalid PA Srv
PA2
Physician Assistant Pilot (PA) claim submissions with the PA as the
submitting physician must identify the solo billing number of the supervising
physician in the “Refer Physician” field. - Invalid PA Claim
PA3
The physician and/or referring physician fields on the PA Pilot claim
submission contain billing numbers which are not affiliated to the PA Pilot
group number. Not registered for PA
PA4
PA5
PA Registrn on S/D Err
PA Affiliation Error
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PA6
R01
R02
PA Affil’n on S/D Err
Missing HSN
Invalid HSN
R03
R04
R05
R06
R07
R08
Invalid/Missing Province Code
Service Excluded from RMBS
Provincial code is 'ON' (Ontario) which is not valid for RMBS
Wrong Provider for RMBS
Invalid Pay Type for RMBS
Invalid Referral Number
TM1
TM2
TM3
TM4
TM5
TM6
TM7
TM8
V02
V05
V06
V07
V08
Dup Telemed Claim, Same patient (uninsured)
Can’t Bill with MSD/CNC AP
Service not Telemedicine Payable
Non Telemed Claim paid for same patient
Telemed Claim Paid for same patient
Registration not in effect on Service Date
Dental Service not eligible for Telemedicine
Not eligible for Store FD
Invalid Region Code
Error - Clm No/Serv Date
Incorrect Clinic Code
Invalid Pract. Number
Invalid Specialty Code
 Specialty code is missing/not 2 numerics
 Not a valid specialty code
 Specialty code is 27 and provider number is not 599993
 Specialty code is 90 and provider number is not 991000
 Specialty code is 49, 50, 51, 52, 53, 54, 55, 70 and 71 and the health
care provider number does not begin with 4
 Specialty code is 56 and health care provider number does not begin
with 80 or 81
with 86 or 839985
with 87
with 88 or 89 or not in range 830000 – 839984
February 2014
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Version 1.0
Claims Submission
 Specialty code is 80 or 81 and health care provider number does not
begin with 82
V09
V10
V12
V13
V14
V16
V17
V18
V20
Invalid Referral Number
 Patient’s last name is missing/not alphabetic (A - Z)
 First field position is blank
 RMB claim only
 Patient’s first name is missing/not alphabetic (A - Z)
 First field position is blank
 RMB claim only
 Patient’s date of birth is missing/invalid format
 Month not in the range of 01 – 12
 Not 8 numerics (new MRI format)
 Day is outside acceptable range for month
Patient sex must be ‘1’ (male) or ‘2’ (female)
RMB claim only
Unacceptable Diagnostic Code
Not numeric
Health care provider number is 82XXXX and diagnostic code is not 4
numerics or is 3 numerics and not 070, 072, 880 or 971
Fee schedule code is G423, G424 and diagnostic code is not 360, 371 or
376
Payee must be ‘P’ (Provider) or ‘S’ (Patient)
In-patient admission date is not 8 numerics
Month of admission is not in the range of 01 - 12
Day of admission is outside the acceptable range for month
In-patient admission date is later than Ministry of Health system run date
Service code is A007, patient is over 2 years old and diagnostic code is ‘916’
or service code is A003 and the patient is under 16 years old and the
diagnostic code is ‘917’
V21
V22
V23
V28
V29
V30
V31
Diagnostic Code Required
Invalid Diagnostic Code
Check No. Of Services
Invalid Hospital Number
Invalid In-Out-Pat-Ind
FSC/DX Code Combination NAB
Missing any of the following: group number, health care provider number,
specialty code
V34
 Service code begins with ‘V1’ and health care provider number does not
begin with 88 or 89, or in range 830000 - 839984 (and the reverse of this
February 2014
4 - 19
Version 1.0
Claims Submission
condition)
begin with 86 or is 839985 (and the reverse of this condition)
begin with 87 (and the reverse of this condition)
begin with 80, 81, 84 or 85 (and the reverse of this condition)
begin with 82 (and the reverse of this condition)
 Service code begins with ‘T’ and health care provider number does not
begin with 4, excluding fee schedule codes J99-- (and the reverse of this
condition)
 Service code begins with ‘H4’ and health number is not a sessional
reference number
V35
V36
V39
V40
V41
V42
V47
V50
V51
V53
V62
V63
Invalid OOP/OOC Service
Check input criteria required for sessional billing
Number of items exceeds the maximum (99)
Service code is missing
Service code is not in the format ANNNA where:
A is alphabetic (A - Z)
NNN is numeric (001 - 999)
A is alphabetic (A - C)
Fee submitted is missing/not 6 numerics
Fee submitted is not in the range ‘000000’ - ‘500000’ ($$$$cc)
Number of services is missing/not 2 numerics
Number of services is not in the range ‘01 - 99’
Fee submitted is not evenly divisible (to the cent) by the number of services
Service Date Pre Initial Visit
Invalid location code - must be blank or four numerics. If present, must be
valid based on MOHLTC Residency Code Manual
Invalid FSC-Magnetic Tape/Disk
Invalid service location indicator – assigned when a Service Location
Indicator (SLI) code included with a hospital diagnostic service billing from a
participating hospital physician/group is not of the five valid SLI codes (HDS,
HED, HIP, HOP or HRP)
Referring Laboratory Number must start with 5 (5###)
February 2014
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Version 1.0
Claims Submission
V64
Missing service location indicator – assigned when a hospital diagnostic
service is billed by a participating hospital physician/group but a service
location indicator code was not included
V65
Missing master number – assigned when SLI code HDS, HED, HIP, HOP or
HRP is included with a diagnostic service billing from a participating hospital
physician/group but a master number was not included
V66
Missing admission date – assigned when SLI code HIP is included with a
diagnostic service billing from a participating hospital physician/group but an
admission date was not included
V67
Missing master number and admission date – assigned when a SLI code HIP
is included with a diagnostic service billing from a participating hospital/group
but a master number and admission date were both not included
V68
Incorrect service location indicator – assigned when a diagnostic service is
billed from a participating hospital physician/group with a master number and
admission date but the SLI code is not HIP
V69
V70
V71
VHB
VH1
VH2
VH3
VH4
VH8
VH9
VJ5
Serv Dte Invalid for SLI
Date of service is greater than the file/batch creation date
Invalid Dental Master No.
No HN Req’d for FSC
Health Number is Invalid
HN is Missing
Invalid Payment Program
Invalid Version Code
No Match on DOB with HN
HN Not Reg’d with MOH
 Date of Service is missing/not 8 numerics
 Month is not in the range 01 - 12
 Day is outside acceptable range for month
 Date of Service is greater than Ministry of Health system run date
Stale-dated Claim
Invalid SEAMO Prvdr Code
Invalid Venue Type
Invalid Clinic Number
Invalid Healthcare Item
Invalid IP/OP Indicator
Invalid HC Item Cde Fmt
Invalid WCB Service
VJ7
VS1
VS2
VS3
VS4
VS5
VS6
VW1
February 2014
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Claims Submission
4.10 Error Report Messages
02
03
04
05
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
Incorrect District code 0 Correct & resubmit
Date of service does not match OP report - correct & resubmit
Special Visit premium payable only when submitting with FSC from the
general listings
No receipt of supporting documentation requested by MOH
Fee Schedule Code(s) used is not correct. Please resubmit using appropriate
code(s) from OHIP Schedule of Benefits
Resubmit as RMB Claim
Bill Patient or Quebec Medicare
Please advise Patient to contact MOH re eligibility /card status/address
Service date is prior to newborn’s date of birth
Fee billed low – check for current SOB fee
No. of Services exceed Maximum allowed
Cannot be claimed alone/service date mismatch
E409/E410 N/A – Resubmit with appropriate assist/anaesthetic premium
codes
Resubmit with man review indicator and provide supporting documentation for
two assistants
Resubmit with manual review indicator and forward copy of OP Report
Resubmit with manual review documentation i.e. consultation report/Hospital
Records
Records indicate patient deceased/ Please clarify or confirm.
Code submitted requires prior approval
Hospital visits claimed by more than one physician – please clarify role in
patient’s care
Claims appearing on previous RA’s as Over/Under Payments should not be
resubmitted; please use inquiry form for payment adjustment requests.
Incomplete newborn registration – have parent/guardian contact MOH
One house call assessment (A901) allowed per visit. Please resubmit claim
with appropriate service code
This duplication submission is being returned; Original submission currently
on file pending medical consultant adjudication
Resubmit with manual review indicator with written explanation for detention.
Total time spent with patient including consultation/assessment indicated.
Discrepancy between claim and documentation. Resubmit claim and
documentation.
February 2014
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Claims Submission
4.11 Explanatory Codes
30
31
32
35
Service is not a benefit of OHIP
Not a valid network service
OHIP records show service(s) on this day claimed previously
36
OHIP records show service has been rendered by another Practitioner,
Group, Lab
Effective April 1, 1993 the listed benefit for this code is 0 LMS units
Service or related service allowed only once for same patient
Specialty code restriction on FSC
37
40
45
48
OHIP records show this service rendered has been claimed previously (used
on Pay Practitioner duplicate claims)
Paid as submitted - clinical records may be requested for verification purposes
49
50
51
52
53
54
55
56
57
58
59
60
62
66
70
80
C1
C2
C3
Paid according to the average fee for this service. Independent consideration
will be given if clinical records/operative reports presented.
Paid in accordance with the Schedule of Benefits
Fee Schedule Code changed in accordance with Schedule of Benefits
Fee-for-service assessed by medical consultant
Fee allowed according to appropriate item in a previous Schedule of Benefits
Interim payment - claim under review
Deduction is an adjustment on an earlier account
Claim under review
This payment is an adjustment on an earlier account
Claimed by another physician within group
Practitioner’s notification - WCB claims
Not a benefit of the Reciprocal Medical Billing Agreement
Claim assessed by Assessment Officer
Reduced per APP Funding Contract
OHIP records show corresponding procedure(s) on this day claimed
previously by another physician
Technical fee adjustment for hospitals
Allowed as repeat/limited consultation/midwife-requested emergency
assessment
Allowed at re-assessment fee
Allowed at minor assessment fee
February 2014
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Version 1.0
Claims Submission
C4
C5
C6
C7
Consultation not allowed with this service - paid as assessment
Allowed as multiple systems assessment
Allowed as Type 2 admission assessment
An admission assessment (C003A) or general re-assessment (C004A) may
not be claimed by any physician within 30 days following a pre-dental/preoperative assessment
C8
Payment reduced to geriatric consultation fee – maximum number of
comprehensive geriatric consultations has been reached
C9
Allowed as in-patient interim admission orders – initial assessment already
claimed by other physician
D1
D2
D3
D4
D5
D6
D7
D8
D9
DA
DB
DC
Allowed as repeat procedure - initial procedure previously claimed
Additional procedures allowed at 50%
Not allowed in addition to visit fee
Procedure allowed at 50% with visit
Procedure already allowed - visit fee adjusted
Limit of payment for this procedure reached
Not allowed in addition to other procedure
Allowed with specific procedures only
Not allowed to a hospital department
Maximum for this procedure reached - paid as repeat/chronic procedure
Other dialysis procedure already paid
Procedure paid previously not allowed in addition to this procedure – fee
adjusted to pay the difference
DD
DE
DG
Not allowed as diagnostic code is unrelated to original eye exam
Lab tests already paid - visit fee adjusted
Diagnostic/Miscellaneous services for hospital patients are not payable on a
fee-for-service basis in the Hospital Global budget.
DH
DL
DM
Ventilatory support allowed with Haemodialysis
Allowed as laboratory tests in private office
DM
Paid/disallowed in accordance with MOH policy regarding an Emergency
Department Equivalent
Paid/disallowed in accordance with MOH policy regarding an emergency
department equivalent
DN
Allowed as pudenal block in addition to procedure - as per stated OHIP policy
DP
Procedure paid previously allowed at 50% in addition to this procedure - fee
adjusted to pay the difference
February 2014
4 - 24
Version 1.0
Claims Submission
DS
DT
DV
DX
E1
E2
E4
E5
EA
Not allowed – mutually exclusive code billed
In-patient technical fee not allowed
Service is included in Monthly Management Fee for LTC patients
Diagnostic code not eligible with FSC
Service date prior to start of eligibility
Incorrect version code for service date
Service date after the eligibility termination date
Service date not within an eligible period
Service date is not within an eligible period - services provided on or after the
20th of this month will not be paid unless eligibility status changes
EB
EF
Coding added/changed in accordance with Schedule of Benefits
Incorrect version code - services provided on or after the 20th of this month
will not be paid unless the current version code is provided
EV
F1
F2
F3
F5
F6
FF
G1
GF
H1
H2
H3
H4
H5
H6
H7
H8
H9
HA
Check health card for current version code
Additional fractures/dislocations allowed at 85%
Allowed in accordance with transferred care
Previous attempted reductions (open or closed) allowed at 85%
Two weeks aftercare included in fracture fee
Allowed as Minor/Partial Assessment
Additional payment for the claim shown
Other critical/comprehensive care already paid
Coverage lapsed - bill patient for future claims
Admission assessment or ER assessment already paid
Allowed as subsequent visit - initial visit previously claimed
Maximum fee allowed per week after 5th week
Maximum fee allowed per week after 6th week to pediatricians
Maximum fee allowed per month after the 13th week
Allowed as supportive or concurrent care
Allowed as chronic care
Hospital number and/or admission date required for in-hospital service
Concurrent care already claimed by another doctor
Admission assessment claimed by another physician - hospital visit fee
applied
HF
HM
I2
I3
Concurrent or supportive care already claimed in period
Invalid master number used on date of service
Service is globally funded
FSC is not on the IHF licence profile for the date specified
February 2014
4 - 25
Version 1.0
Claims Submission
I4
Records show service has been rendered by another Practitioner, Group or
IHF
I5
I6
I7
I8
I9
J3
J7
L1
L2
L3
L4
L5
L6
Service is globally funded and FSC is not on IHF licence profile
L7
L8
L9
Not allowed - referred specimen
Not to be claimed with prenatal/fetal assessment
Laboratory services for hospital in-patients or out-patients are not payable on
a fee-for-service basis - included in the hospital global budget
LA
LS
M1
Lab service is funded by special Lab Agreement
Paid in accordance to special Lab Agreement
Maximum fee allowed or maximum number of service has been reached
same/any provider
M2
Maximum allowance for radiographic examination(s) by one or more
practitioners
M3
M4
Maximum fee allowed for prenatal care
Maximum fee allowed for these services by one or more practitioners has
been reached
M5
M6
MA
MC
Monthly maximum has been reached
Maximum fee allowed for special visit premium - additional patient seen
Maximum number of sessions has been reached
Maximum number of case conferences has been reached in a 12 month
period
MD
MN
MR
Daily maximum has been exceeded
Maximum number of occipital nerve block sessions has been reached
Minimum service requirements have not been met
Premium not applicable
Claim date does not match patient enrolment date
Confirmation not received
Payment not applicable/expired
Approved for stale dated processing
Claim submitted six months after service date
This service paid to another laboratory
Not allowed to medical Laboratory Director
Not allowed in addition to other laboratory procedure(s)
Not allowed to attending physicians
Not allowed in addition to other procedure paid to another laboratory
Procedure paid previously to another laboratory, not allowed in addition this
procedure - fee adjusted to pay the difference
February 2014
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Version 1.0
Claims Submission
MS
Maximum allowed for sleep studies in a specific period by one or more
physicians has been reached
MX
MY
O1
O2
O3
O4
Maximum of 2 arthroscopy “R” codes with E595 has been reached
Yearly maximum has been exceeded
Fee for obstetric care apportioned
Previous prenatal care already claimed
Previous prenatal care already claimed by another doctor
Office visits relating to pregnancy and claimed prior to delivery included in
obstetric fee
O5
O6
O7
O8
O9
P2
P3
P4
Not allowed in addition to delivery
Medical induction/stimulation of labour allowed once per pregnancy
Allowed as subsequent prenatal visit - initial prenatal visit already claimed
Allowed once per pregnancy
Not allowed in addition to post-natal care
Maximum fee allowed for low birth weight care
Maximum fee allowed for newborn care
Fee for newborn care/low birth weight care is not billable with neonatal
intensive care
P5
P6
P8
P9
PM
Q7
Q8
R1
RD
S1
S2
S3
S4
S5
S6
S7
SA
SB
Over-age for paediatric rates of payment
Over-age for well-baby care
HCC GT 3 months
Complex New patient
Minimum roster size not met
No fee allowed for treatment of immediate family
Lab not licensed to perform this test on date of service
Only one health exam allowed in a twelve-month period
Duplicate, paid in RMBS
Bilateral surgery, one stage, allowed at 85% higher than unilateral
Bilateral surgery, two stage, allowed at 85% higher than unilateral
Second surgical procedure allowed at 85%
Procedure fee reduced when paid with related surgery or anaesthetic
Not allowed in addition to major surgical fee
Allowed as subsequent procedure - initial procedure previously claimed
Normal pre-operative and post-operative care included in surgical fee
Surgical procedure allowed at consultation fee
Normal pre-operative visit included in surgical fee - visit fee previously paid surgical fee adjusted
February 2014
4 - 27
Version 1.0
Claims Submission
SC
SD
SE
Not allowed, major pre-operative visit already claimed
Not allowed, Team/Assist Fee already claimed
Major pre-operative visit previously paid and admission assessment
previously paid - surgery fee reduced by the admission assessment
SF
Most Responsible Physician visit not allowed during post operative period –
surgical fee adjusted.
SV
MRP visit not allowed during post operative period – fee reduced to
subsequent visit fee.
T1
V1
V2
V3
V4
V5
Fee allowed according to surgery claim
Allowed as repeat assessment - initial assessment previously claimed
Allowed as extra patient seen in the home
Not allowed in addition to procedural fee
Date of service was not a Saturday, Sunday or statutory holiday
Only one OVA allowed within a 12-month period for age 19 and under, or 65
and over - and one within 24 months for age 20 - 64
V6
V7
V8
V9
VA
VB
Allowed as minor assessment - initial assessment already claimed
Allowed at medical/specific re-assessment fee
This service paid at lower fee as per stated OHIP policy
Only one initial office visit allowed within a twelve-month period
Procedure fee reduced - consultation/visit fees not allowed in addition
Additional OVA is allowed once within the second year for patients aged 2064, following a periodic OVA
VG
Only one geriatric general assessment premium per patient per 12-month
period
VM
Oculo-visual minor assessment is allowed within 12 consecutive months
following a major eye exam
VP
VS
VX
W4
X2
X3
X4
X5
X6
Allowed with special visit only
Date of service was a Saturday, Sunday or statutory holiday
Complexity premium not applicable to visit fee
Warning: - service location indicator code missing
G.I. tract includes cine and video tape
G.I. tract includes survey film of abdomen
Only one BMD allowed within a 36 month period for a low risk patient
Only one BMD allowed within a 12 month period for a high risk patient
Only one BMD allowed within a 60 month period for a low risk patient
February 2014
4 - 28
Version 1.0
Claims Submission
4.12 Specialty Codes
This is a list of specialties or disciplines recognized by the Royal College of
Physicians and Surgeons of Canada relevant to services covered by the Ministry of
Health and Long-Term Care.
Code
00
Physician
Family Practice and Practice in General
01
Anaesthesia
02
Dermatology
03
General Surgery
04
Neurosurgery
05
Community Medicine
06
Orthopaedic Surgery
07
Geriatrics
08
Plastic Surgery
09
Cardiovascular and Thoracic Surgery
12
Emergency Medicine
13
Internal Medicine
15
Endocrinology
16
Nephrology
17
Vascular Surgery
18
Neurology
19
Psychiatry
20
Obstetrics and Gynaecology
22
Genetics
23
Ophthalmology
24
Otolaryngolgy
26
Paediatrics
27
Non-Physician Lab Director
28
Laboratory Medicine
29
Microbiology
30
Clinical Biochemistry
31
Physical Medicine
33
Diagnostic Radiology
34
Therapeutic Radiology
February 2014
4 - 29
Version 1.0
Claims Submission
35
Urology
41
Gastroenterology
44
46
47
Medical Oncology
Infectious Disease
Respiratory Disease
48
56
Rheumatology
Optometrists
58
Chiropodists
60
61
Cardiology
Haematology
62
63
Clinical Immunology
Nuclear Medicine
64
70
Thoracic Surgery
Oral Radiology
71
Prosthodontics
85
86
Alternate Health Professionals
Generic Referral
99
Code
RMBS OOP/OOC
49
Dental Surgery
50
Oral Surgery
51
Orthodontics
52
Paedodontics
53
Periodontics
54
Oral Pathology
55
Endodontics
Code
Practitioner
56
Optometry
58
Chiropody (Podiatry)
80
Private Physiotherapy Facility (Approved to Provide Home Treatment Only)
81
Private Physiotherapy Facility (Approved to Provide Office/Home Treatment)
Code
Other
Dental
February 2014
4 - 30
Version 1.0
Claims Submission
27
Non-medical Laboratory Director
(Provider Number Must Be 599993)
75
Midwife (Referral Only)
76
85
Nurse Practitioner
Alternate Health Care Profession
90
IHF Non-Medical Practitioner
(Provider Number Must Be 991000)
February 2014
4 - 31
Version 1.0
Claims Submission
4.13 Diagnostic Codes
Alpha
Diagnosis
Abdominal
Abortion
Abrasions
Abruptio Placenta
Abscess
Description
Pain, Masses
Adhesions
Advice
Complete, Incomplete
Missed
Therapeutic
Threatened
Anal or Rectal Regions
Bartholin's Gland
Brain
Breast
Dental
Fallopian Tube, Ovary or Tubo-ovarian
Pilonidal Tissue, Other
Skin and Subcutaneous
Urinary System
Acariasis
Acne
Rosacea
Vulgaris
Acromegaly
Actinomycotic Infection
Addison's Disease
Adenitis Cervical
Adentis - see
Lymphadenitis,
Acute
Adenoids, Chronic
Infection
Adenoma Parathyroid
Adjustment Reaction
Adrenogenital
Syndrome
Adverse Effects
February 2014
Code
787
560
895
634
632
635
640
919
641
566
616
349
611
525
614
682
685
590
133
706
695
706
253
039
255
289
683
474
259
309
255
Of Drugs and Medications, including allergy,
overdose, reactions
4 - 32
977
Version 1.0
Claims Submission
Alpha
Diagnosis
Agammaglobulinemia
Aged Parent Problem
Agranulocytosis
A.I.D.S.
A.I.D.S. (A.R.C.)
Alcoholic Psychosis
Alcoholism
Allergy
Alopecia
Alveolitis, Oral Cavity
Alveolitis, Lung
Amblyopia
Amoebiasis
Amenorrhea
Amino-acid - Acid
Metabolism Disorder
Amputation, Traumatic
Anal
Anaphylaxis
Anemia
February 2014
Description
Or Other Chemicals (e.g., lead pesticides and
venomous bites)
Of Surgical And Medical Care (e.g., wound
infection, wound disruption, other iatrogenic
disease)
Of Physical Factors (e.g., heat, cold, frostbite,
pressure)
Acquired Immune Deficiency Syndrome
Acquired Immune Deficiency Syndrome
Related Complex
Bronchitis
Drugs and Medication
Rhinitis
Lower Limb(s)
Upper Limb(s)
Fissure, Fistula
Stricture
Aplastic
Hemolytic, acquired excluding hemolytic
disease
of newborn
Hemoytic, Hereditary
Iron Deficiency
Pernicious
Sickle Cell
Other Anemias
4 - 33
Code
989
994
998
279
900
288
042
043
291
303
493
977
477
704
525
518
368
006
626
270
894
884
565
569
995
284
283
282
280
281
282
285
Version 1.0
Claims Submission
Alpha
Diagnosis
Aneurysm, Aortic
(non-syphilitic)
Aneurysm, Others
Angina, Ludwig's
Angina Pectoris
Angina, Vincent's
Ankylosing Spondylitis
Ankylosis, Joint
Annual Health
Examination
Anorexia
Anorexia Nervosa
Anuria
Anxiety Neurosis
Aphakia
Appendicitis, Acute
Arrythmias, Cardiac,
Other
Arteriosclerosis
Arteriosclerotic
Cerebrovascular
Disease, Chronic
Arteriosclerotic Heart
Disease (A.S.H.D.)
Without Symptoms
Arteritis, Temporal
Arthralgia
Arthritis
Description
Adolescent/Adult
With or without abscess or peritonitis
Cerebral with psychoses
Generalized
447
529
413
136
720
718
917
787
307
788
300
360
540
427
298
440
437
412
Osteo
Pygenic
Rheumatoid
Traumatic
Arthrogryposis
(Contracture of Joint)
Asbestosis
Ascites
Asphyxia
Asthma
Astigmatism
Astroblastoma
February 2014
Code
441
446
781
715
711
714
716
728
501
787
799
493
367
191
4 - 34
Version 1.0
Claims Submission
Alpha
Diagnosis
Astrocytoma
Ataxia
Atelectasis
Atherosclerosis
Athlete's Foot
Atrial Fibrillation, Flutter
Autism
Automated Visual Field
Baker's Cyst
Basal Cell Carcinoma
Battered Child
Bed Sore
Bee Sting
Behavior Disorders of
Childhood and
Adolescence
Bell's Palsy
Bends
Benign Prostatic
Hypertrophy (B.P.H.)
Birth Trauma
Bites, Non-venomous
Bites, Venomous
Bleeding
Blepharitis
Blindness
Blood Poisoning
Boil
Botulism
Bradycardia
Branchial Cyst
Bronchiectasis
Bronchitis
Description
AVF test
351
994
600
Post-menopausal
Rectal
Acute
Allergic
Chronic
Brucellosis
Bruises
Buerger's Disease
February 2014
Code
191
780
518
440
110
427
299
918
727
173
899
707
989
313
4 - 35
767
919
989
627
569
373
369
038
680
136
427
744
494
466
493
491
023
919
443
Version 1.0
Claims Submission
Alpha
Diagnosis
Bullet Wound
Bunion
Burns
Bursitis
Calculus (Stone)
Calluses
Candidiasis
Canker Sore
Carbuncle
Cardiac Arrest
Cardiospasm
Carpal Tunnel Syndrone
Cartilage Tear
Cataract
Carcinoma In Situ
Description
If open wound use code for appropriate area –
see Open Wounds
If internal injury use
Thermal or Chemical
Bile Duct
Bladder
Kidney
Lacrimal Duct
Liver
Prostate
Salivary Glands
Ureter
Congenita
Excluding Diabetic or Congenital
Breast
Digestive Organs
Genito-urinary System
Skin
Respiratory System
Other
Celiac Disease
Cellulitis
Cephalgia
Cephalo-pelvic
Disproportion
Cerebral Degenerations,
Other
Cerebral Haemorrhage
Cerebral Ischaemia,
Transient
February 2014
Code
869
727
949
727
576
592
592
368
573
592
527
592
700
112
528
680
427
530
739
718
744
366
233
230
233
232
231
234
579
682
780
653
331
432
435
4 - 36
Version 1.0
Claims Submission
Alpha
Diagnosis
Cerebral Palsy
Cerbro-vascular
Accident,
Acute (C.V.A.)
Cerrebral Thrombosis
Cerumen in Ear
Cervical Dysplasia
Cervical Erosion
Cervical Hyperplasia
Cervicitis
Description
During Pregnancy
Chalazion
Chicken Pox
Child Abuse, Child
Neglect
Childhood Psychosis
Cholecystitis without
Gallstones
Cholelithiasis
(Gallstones)
Chorea
Chorioretinitis
Choroiditis
Chronic Fatigue
Syndrome
Circumcision, Newborn
Cirrhosis
Claudication,
Intermittent
Claustrophobia
Cleft Palate, Lip
Club Foot
Coagulation Defects
Coarctation of Aorta
Coccydynia
Cold, Common
Cold Sore
Colic, Renal
Colitis
February 2014
Code
343
436
436
388
622
622
752
616
646
373
052
899
299
575
With or Without Cholecystitis
574
363
636
363
795
Liver, Alcoholic, Biliary
Mucus
Ulcerative
4 - 37
609
571
443
300
749
754
286
747
724
460
054
788
564
556
Version 1.0
Claims Submission
Alpha
Diagnosis
Colon
Colon Positive Fecal
Occult Blood
Colon Surveillance
Colon Family History of
Colon Cancer
Colon Screening
Compression of
Umbilical Cord
Concussion
Conduction Disorders,
Other
Condyloma
Condylomata
Accuminata
Congenital Anomalies
Description
Spastic, Irritable
546
547
548
762
850
426
099
079
Autosomal, Chromosomal
Circulatory System
Digestive System
Ear, Face, Neck
Eye
Genital Organs
Heart
Limbs
Musculoskeletal System
Nose and Respiratory System
Pylorus, Mouth, Esophagus, and Stomach
Sex Chromosomes
Urinary System
Congestive Heart Failure
Conjunctiva Disorders
(e.g., Conjuntivitis)
Conn's Syndrome
Constipation
Contraceptive Advice
Contusions
Convulsions
Cord Prolapse
Corneal Ulcer
Corns
February 2014
Code
564
545
4 - 38
758
747
751
744
743
752
746
755
756
748
750
758
753
428
372
255
564
895
919
780
762
370
700
Version 1.0
Claims Submission
Alpha
Diagnosis
Coronary Artery
Disease,
Chronic, Without
Symptoms
Coronary Insufficiency,
Acute
Coronary Thrombosis
Cough
Coxsackie Pleurodynia
Cramps of Leg
Cretinism
Crohn's Disease
Croup
Cushing's Syndrome
C.V.A.
Cyst
Description
413
Cerebrovascular Accident
Baker's
Bartholin's Gland
Bone
Branchial
Breast
Dental
Dermoid
Hydatid All Sites
Lip (mucocele)
Ovarian
Pilonidal
Renal
Sebaceous
Urachal
Cystic Fibrosis
Cystic Disease, Chronic
or
Cystic Mastitis
Cystinuria
Cystitis
During Pregnancy
Cystocele
Dacrocystitis
Deafness, All Types
Decubitus Ulcer
February 2014
Code
412
4 - 39
410
786
074
781
243
555
464
255
436
727
616
213
745
610
525
228
122
210
220
685
223
706
753
277
610
270
595
634
618
375
389
707
Version 1.0
Claims Submission
Alpha
Diagnosis
Deficiency
Dehydration
Delirium Tremens
Delivery
Dementia
Dental Caries
Depression, Reactive
Depressive or Other
Non-psychotic Disorder,
Not
Classified Elsewhere
Dermatitis
Dermatomyositis
Detachment, Retinal
Deviated Nasal Septum
Diabetes Mellitus
(Including
Complications)
Diabetes Mellitus with
Ocular Complications
Diabetes Insipidus
Diaper Rash
Diarrhea
Difficulty at Work
Diphtheria
Diplopia
Disease
February 2014
Description
Mental
Iron
Nutritional, Vitamin
Normal
With Other Complications
With Placenta Praevia, Abruptio Placenta
Senile, Presenile
Allergic, Atopic
Contact
Neuro
Seborrheic
Code
319
280
269
277
291
650
669
641
290
521
300
311
691
692
691
690
710
361
470
250
248
Addison's
A.I.D.S
Arteriosclerotic
Arteriosclerotic Heart
Bacterial
Buerger's
Breast Cystic, Chronic
4 - 40
253
691
009
905
032
368
255
042
437
412
040
443
610
Version 1.0
Claims Submission
Alpha
Diagnosis
Dislocation
Diverticulitis
Divorce
Dizziness
Down's Syndrome
February 2014
Description
Bright's
Christmas
Crohn's
De Quervaine's
Duchennes
Graves
Hansen's
Hashimoto
Hemolytic of Newborn
Hirchsprung's Megacolon
Hodgkin's
Huntington's Chorea
Hypertensive Heart
Hypertensive Renal
Ischaemic Heart
Legg Perthes
Lung, Other
Marie Strumpell
Meniere's
Motor Neurone
Osgood-Schlatter
Paget's - of bone
Parkinson's
Pelvic - inflammatory, chronic (P.I.D.)
Peripheral Vascular (P.V.D.)
Raynaud's
Respiratory System, other
Still's
Tay-Sachs
Venereal
Viral, Arthropod-borne
Elbow
Finger
Other
Recurrent
Shoulder
or Diverticulosis of small or large intestine
4 - 41
Code
580
286
555
727
099
242
030
245
773
751
201
349
402
403
413
732
518
720
386
349
732
731
332
614
443
519
398
714
330
099
066
832
834
839
718
831
562
901
780
758
Version 1.0
Claims Submission
Alpha
Diagnosis
Drug Addiction,
Dependence
Drug Overdose
Drug Psychosis
Duodenal Ulcer, With or
Without Haemorrhage or
Perforation
Dupuytren's Contracture
Dwarfism
Dysentery
Dysfunction
Dyslalia
Dyslexia
Dysmenorrhea
Dyspareunia
Dyspepsia
Dysphagia
Dysplasia, Cervical
Dyspnea
Dystrophy, Muscular
Dysuria
Echinococcosis
Eclampsia
Economic Problems
Ectopic Pregnancy
Ectropion
Eczema
Edema
Educational Problems
Embolism
Description
977
292
532
Amoebic
Ovarian
Pituitary Gland
Sexual
Not yet diagnosed
Post-partum pulmonary
Pulmonary
Emphysema
Encephalitis
Viral, Mosquito Borne
Encephalomyelitis
Encephalopathy,
Hypertensive
Endocarditis
February 2014
Code
304
728
253
006
256
253
306
315
315
625
625
536
787
622
786
359
786
122
642
897
633
374
691
785
902
677
415
492
323
062
323
437
429
4 - 42
Version 1.0
Claims Submission
Alpha
Diagnosis
Endometriosis
Enteritis
Enterocele
Entropion
Enuresis
Eospinophilia
Epididymitis
Epiglottitis, Acute
Epilepsy
Epistaxis
Erosion, Cervical
Erysipelas
Erythema, Multiforme or
Nodosum
Esophagitis
Eustachian Tube
Disorders
Eye Disorders, Other
Eyelid Disorders, Other
Facial Nerve Disorders
False Labour
Family Disruption
Family Planning
Fanconi Sydrome
Fever
Description
Acute or Chronic
Regional
Gastro
Mental Disorder
530
381
Glandular
Hay
Rheumatic with or without Endocarditis,
Myocarditis or Pericarditis
Scarlet
Typhoid
Fibrillation
Fibro-adenosis of Breast
Fibrosis
Cystic
Pulmonary
Fissure, Anal
Fistula, Anal
Flat Foot
February 2014
Code
617
615
555
009
618
374
307
288
604
464
345
786
622
035
695
4 - 43
379
374
351
644
901
895
270
075
477
391
034
002
427
610
277
515
565
565
734
Version 1.0
Claims Submission
Alpha
Diagnosis
Flutter, Atrial or
Ventricular
Food Poisoning
Foreign Body
Fractures, Fracturedislocation
Frigidity
Frostbite
Fungus - See Mycoses
Furunculosis
Gallstones (Calculus)
Ganglion
Gastric Ulcer
Gastritis
Gastro-enteritis and
Gastro-enteritis, Viral
German Measles
(Rubella)
Gingivitis
Glandular Fever
Glaucoma
Glmerulonephritis,
Acute
February 2014
Description
Eye or other tissues
Ankle
Carpal Bones
Clavicle
Facial Bones
Femur
Fibula
Humerus
Metacarpals
Pelvis
Phalanges
Radius
Ribs
Skull
Spontaneous
Tibia
Ulna
Vertebral Column with spinal cord damage
Vertebral Column without spinal cord damage
Other
Cholelithiasis, with or without Cholecystitis
Code
427
005
930
824
814
810
802
821
823
812
815
808
816
813
807
803
733
823
813
806
805
829
302
994
680
574
727
531
535
009
056
523
075
365
580
4 - 44
Version 1.0
Claims Submission
Alpha
Diagnosis
Glossitis
Goitre
Gonococcal Infections
Gout
Granuloma, Pyogenic
Gynecomastia
Habit Spasms
Haemorrhage, Eye
Haemorrhage,
Intracranial
Haemorrhage in Early
Pregnancy
Haemorrhage, Post
Partum
Haemorrhagic
Conditions, Other
Haemorrhoids
Halitosis
Hallux Valgus or Varus
Hammer Toe
Hansen's Disease
(Leprosy)
Hay Fever
Headache (Cephalgia)
Description
Exophthalmic
Nontoxic Nodular
Simple Thyroid
640
666
287
455
787
735
735
030
Migraine
Tension
Except tension and migraine
Heart Blocks
Heartburn
Heart Disease, All Other
Forms
Heart Failure,
Congestive
Helminthiases
Hemangioma
Hematemesis
Hematuria
Hemiplegia
February 2014
Code
529
242
241
240
098
274
686
611
307
379
432
477
346
307
780
426
787
429
428
128
228
787
599
599
4 - 45
Version 1.0
Claims Submission
Alpha
Diagnosis
Hemolytic Anemia,
Hereditary
Hemolytic Disease of
Newborn
Hemophilia
Hemoptysis
Hepatitis
Hernia
Herpes Genitalis
Herpes Simplex
Herpes Zoster
Hiccough
High Birthweight Infant
High Myopia
Description
773
Femoral, umbilical, ventral, diaphragmatic or
hiatus hernia with obstruction
hiatus hernia without obstruction
Inguinal with or without obstruction
Greater than 9 diopters, irregular astigmatism
resulting from post-corneal grafting or corneal
scarring from disease
Hirsutism
Histoplasmosis
Hives
Hodgkin's Disease
Hunner's Ulcer
Hyaline Membrane
Disease
Hydrocele
Hydrocephalus
Hydronephrosis
Hyperactive Child
Hyperaldosteronism
Hypercalcemia
Hyperchlorhydria
Hypercholesterolemia
Hyperemesis
Gravidarum
Hyperkeratosis
February 2014
Code
282
286
786
070
552
553
550
099
054
053
787
766
371
709
115
708
201
595
769
603
742
591
314
255
259
536
272
643
701
4 - 46
Version 1.0
Claims Submission
Alpha
Diagnosis
Hyperkinetic Syndrome
of
Childhood
Hypermenorrhea
Hypermentropia
Hyperopia
Hyperplasia
Hypertension, Essential
Hypertensive
Encephalopathy
Hypertensive Heart
Disease
Hypertensive Renal
Disease
Hypertensive
Retinopathy
Hyperthyroidism
Hypertrophy
Hyperventilation
Hypochlorhydria
Hypogammaglobulinemi
a
Hypoglycemia
Hypomenorrhea
Hypotension
Hypothyroidism
Hysteria
Ileitis, Regional
Ileus, Paralytic
Illegitimacy
Immunity Disorders
Immunization
Impaction of Intestine
Impetigo
Imprisonment
Incontinence of Urine
February 2014
Description
Adrenal
Endometrial
Code
314
626
367
367
259
621
401
437
402
403
362
Benign Prostatic (B.P.H.)
Breast
Tonsils, Adenoids
Acquired
Congential
All types
4 - 47
242
600
611
575
786
536
279
259
626
447
244
243
300
555
560
903
279
896
560
684
906
788
Version 1.0
Claims Submission
Alpha
Diagnosis
Indigestion
Inertia, Uterine
Infarction
Infection
Infertility
Infestation
Influenza
Ingrown Nail
Inguinal Hernia with or
without Obstruction
Injury
In-laws Problem
Insufficiency
Intertrigo
Intervertebral Disc
Disorders
Intussusception
Iritis
Irregular Astigmatism
February 2014
Description
Myocardial Acute
Myocardial Old, Without Symptoms
Pulmonary
Actinomycotic
Gonococcal
Intracranial
Meningococcal
Monilia all sites
Nipple, Post-partum, Salmonella
Other Human Immunodeficiency Virus Infection
Tonsils, Adenoids Chronic
Trichomonas Vaginalis
Tuberculous, Primary, Including Recent
Positive
T.B. Skin Test Conversion
Upper Respiratory
Wound
Pinworm
Tapeworm - all types
Head
Internal to Organ
Superficial
Other
Acute Coronary
Mitral
Resulting from post corneal grafting or corneal
scarring from disease
4 - 48
Code
536
661
410
412
415
098
039
298
036
112
003
044
474
131
010
460
998
628
127
123
147
703
550
854
869
919
959
900
413
394
695
722
560
364
371
Version 1.0
Claims Submission
Alpha
Diagnosis
Ischaemic Heart
Disease, Acute
Ischamia, Transient
Cerebral
Itchy Condition, Other
Jaundice
Joint
Korsakov's Psychosis
Kyphosis
Labyrinthitis
Laceration
Lactic Acidosis
Laryngitis, Acute
Legg-perthes Disease
Leiomyoma
Legal Problems
Leprosy (Hansen's
Disease)
Leukoplakia
Description
435
Ankylosis
Arthrogryposis
Contracture
Derangement, Loose Bodies
Pain
Swelling, Masses
Tuberculosis
Other Disease of
Keloid
Keratitis
Keratoconus
Klinefelter's Syndrome
Perineal
Except Limbs
Lower Limb(s)
Upper Limb(s)
Oral Mucosa
Tongue
Lice, Head or Body
Lipoid Metabolism
Disorder
Lipoma
Lipoprotein Disorders
Lips, Diseases of
February 2014
Code
413
698
787
718
728
718
718
781
781
015
739
701
370
376
758
291
737
386
664
879
894
884
259
464
732
218
906
030
528
529
132
272
214
272
528
4 - 49
Version 1.0
Claims Submission
Alpha
Diagnosis
Litigation
Lordosis
Low Birthweight Infant
Low Vision
Ludwig's Angina
Lumbago
Lumbar Strain
Lupus Erythematosus
Lupus Erythematosus
Disseminated
Lymphadenitis Acute
Lymphangioma
Lymphangitis
Lymphedema
Lymphosarcoma
Macrognathism
Malabsorption
Syndrome
Malaria
Malnutrition,
Unspecified
Malocclusion
Malpresentation
Manic Depressive
Psychosis
Marie-Strumpell
Spondylitis
Marital Difficulties
Masses
Mastitis
Description
683
228
457
457
200
524
579
136
263
524
652
296
720
Circulatory System
Respiratory System
Digestive System
Cystic
Post-partum
Mastoiditis
Measles
German, Rubella
Melancholia,
Involutional
Melena
February 2014
Code
906
737
765
369
529
724
724
695
710
898
785
786
787
788
610
675
383
055
056
296
787
4 - 50
Version 1.0
Claims Submission
Alpha
Diagnosis
Meniere's Disease
Meningioma (Benign)
Meningitis
Description
Bacterial, Central Nervous System
Due to Other Organisms
Enterovirus
Infectious
Menigocele
Meningococcal Infection
Meningomyelocele
Meniscus or Cartilage
Tear
Menopause
Menorrhagia
Menstruation Disorders
Mental Deficiency,
Retardation
Mesenteric Artery
Occlusion
Metabolic Disorders,
Other
Metrorrhagia
Micrognathism
Migraine
Mitral Insufficiency or
Stenosis
Mole
Monilia Infection, All
Sites
Mononucleosis,
Infectious
Monoplegia
Motor Neurone Disease
Motor Retardation
Multiple Pregnancy
Multiple Sclerosis
Mumps
Muscle Spasms
Muscular Dystrophy
Muscular Rheumatism
Myasthenia Gravis
February 2014
Code
386
225
320
321
047
036
741
036
741
718
627
626
626
319
557
277
626
524
346
394
216
112
075
349
349
315
651
340
072
728
359
729
358
4 - 51
Version 1.0
Claims Submission
Alpha
Diagnosis
Mycoses, All Types
Myocarditis
Myocardial Infarction
Myoneural Disorders
Myopia
Myositis
Myxedema
Naevus, Pigmented
Narcolepsy
Nasal Polyp
Nasopharyingitis, Acute
Nausea
Neck Sprain/Strain
Neoplasm (Benign)
Neoplasm (Benign)
(Continued)
February 2014
Description
Artherosclerotic
Rheumatic
Coxsackie
Acute
Old
Bladder
Bone
Brain
Breast
Cartilage
Cervical Polyp
Connective and other soft tissue
Dermato Fibroma
Digestive System, other parts
Eye
Genital Organs, female, other
Genital Organs, male, other
Hemangioma
Intrathoracic Organs
Kidney
Leiomyoma
Lip
Lipoma
Lymphangioma
Oral Cavity
Other Endocrine Glands/related structures
Ovary, e.g. Ovarian Cyst
Peripheral Nerves
4 - 52
Code
117
429
391
074
410
412
367
367
729
244
216
349
471
460
787
847
223
213
225
217
213
218
215
216
230
224
221
222
228
212
223
218
210
214
228
210
227
220
225
Version 1.0
Claims Submission
Alpha
Diagnosis
Neoplasm (Malignant)
(Continued)
February 2014
Description
Peritoneum
Pharynx
Respiratory System
Seborrheic Wart
Skin
Spinal Cord
Thyroid
Ureter
Uterine Fibroid
Other
Anus
Astroblastoma, Astrocytoma
Basal Cell
Bladder
Bone
Brain
Breast, Female
Broad, Ligament
Bronchus
Cancer, Multiple Sites
Carcinomatosis
Cervix
Cranial Nerves
Esophagus
Eye
Fallopian Tube
Gallbladder and Extra Hepatic Bile Ducts
Genital Organs, female, other
Genital Organs, male, other
Gum
Hodgkin's Disease
Hypopharynx
Kidney
Large Intestine Excluding Rectum
Larynx
Leukemia, Lymphatic, Lymphocytic, Lymphoid
Leukemia, Monocytic
4 - 53
Code
211
210
212
216
216
225
226
223
218
229
154
191
173
188
170
191
174
183
162
199
198
180
171
192
150
190
183
156
184
187
143
201
148
189
153
161
204
206
Version 1.0
Claims Submission
Alpha
Diagnosis
(Continued)
February 2014
Description
Leukemia, myeloid including granulocytic and
myelogenous
Leukemia, other types
Leukemia, plasma cell
Lip
Liver, primary malignancy (not secondary
spread
or metastatic)
Lung
Lymphoid and Histiocytic Tissue, other
Lymphosarcoma
Major Salivary Glands
Male Breast
Melanoma of Skin
Metastic Disease, secondary spread
Mouth, Floor of
Multiple Myeloma
Nasal Cavities, middle ear and accessory
sinuses
Nasopharynx
Oropharynx
Other Endocrine Glands and related structures
Other and ill-defined sites within the digestive
organs and peritoneum
Other and ill-defined sites within the lip,
oral cavity and pharynx
Other and ill-defined sites
Other and unspecified parts of mouth
Other sites within the respiratory system
and intrathoracic organs
Other Specified Leukaemia
Ovary
Pancreas
Placenta
Pleura
Prostate
Recto Sigmoid
Rectum
Reticulosarcoma
Retroperitoneum and Peritoneum
4 - 54
Code
205
208
203
140
155
162
202
200
142
175
172
199
144
203
160
147
146
194
159
149
195
145
165
207
183
157
181
163
185
154
154
200
158
Version 1.0
Claims Submission
Alpha
Diagnosis
Neoplasm Unspecified
Neoplasm Of Uncertain
Behaviour
Nephrotic Syndrome
Neuralgia, Trigeminal
Neurasthenia
Neuritis, Idiopathic
Peripheral
Neuritis, Optic
Neurodermatitis
Neurosis
Neutropenia
Nocturia
Non-psychotic Disorder
Not
Classified Elsewhere
Nutritional and Vitamin
Deficiencies
Obesity
February 2014
Description
Secondary Cancer
Secondary Neoplasm of Lymph Nodes
Secondary Neoplasm of Respiratory and
Digestive System
Skin Malignancies, other
Small Intestine, including duodenum
Spinal Cord
Stomach
Testis
Thymus, Heart and Mediastinum
Thyroid
Tongue
Urinary Organs, other
Uterus, body of
Uterus, part unspecified
Vagina
Vulva
Other Malignant Tumours
(e.g., Polycythemia Vera)
Digestive and Respiratory Systems
Endocrine Glands and Nervous System
Genitourinary Organs
Other and Unspecified Sites and Tissues
Anxiety, Obessive Compulsive
Code
198
196
197
173
152
192
151
186
164
193
141
189
182
179
184
184
199
239
235
237
236
238
581
350
300
356
377
691
300
288
788
311
269
278
4 - 55
Version 1.0
Claims Submission
Alpha
Diagnosis
Obsessive Compulsive
Neurosis
Obsessive Compulsive
Personality
Obstipation
Obstructed Labour
Obstruction
Obstructive Pulmonary
Disease
Occupational Problems
Oligomenorrhea
Oligouria
Onychogryposis
Oophoritis
Open Wounds
Orchitis
Osgood-Schlatter
Disease
Osteitis Deformans
Osteoarthritis
Osteochondritis,
Osteochondritis
Dissecans
Osteomyelitis
Osteoporosis
Otitis Externa
Otitis Media, Serous
Otitis Media,
Suppurative
Otosclerosis
Ovarian Dysfunction
Overdose, Drug
Pain
Palsy
February 2014
Description
Code
300
301
Esophagus
Intestine
Lacrimal Duct
Chronic, other
Unemployment, difficulty at work
Acute or chronic
Except Limbs
Lower Limb(s)
Upper Limb(s)
564
660
530
560
375
496
905
626
786
703
614
879
894
884
604
732
731
715
732
730
730
380
381
382
Failure
Abdominal
Chest
Joint, Leg, Muscle
Bell's
4 - 56
387
256
977
787
785
781
351
Version 1.0
Claims Submission
Alpha
Diagnosis
Pancreas Endocrine
Disorders
Paralysis, Facial
Paralytic Ileus
Paranoid Personality
Disorder
Paranoid States
Paraphimosis
Paraplegia
Paratyphoid Fever
Parathyroid Gland
Disorders
Parent-child Problems
Description
Cerebral
351
560
301
297
605
349
002
252
(e.g., Child Abuse, Battered Child, Child
Neglect)
Parkinson's Disease
Paronychia
Paroxysmal Tachycardia
Patent Ductus
Arteriosus
Pediculosis
Pelvic Inflammatory
Disease
(P.I.D.)
Performation of
Tympanic
Membrane
Pericarditis
Perinatal Morbidity &
Mortality, Due to
Complications of Labour
or Delivery
Perinatal Disorders of
Digestive System
Periodontal Disease
Peripheral Vascular
Disease
Peritonitis, With Or
Without
Abscess
Personality Disorder
(e.g., Obsessive Compulsive)
February 2014
Code
343
251
4 - 57
899
332
686
427
747
132
614
384
429
763
777
523
443
567
301
Version 1.0
Claims Submission
Alpha
Diagnosis
Pertussis
Pes Planus
Pharyngitis
Phimosis
Phlebitis
Phobias, All Types
P.I.D.
Pilonidal Cyst or
Abscess
Pinworm Infestation
Pituitary Gland
Dysfunction
Placenta Previa
Pleurisy
Description
Paranoid
Schizoid
Pelvic Inflammatory Disease
During Pregnancy
127
253
With or Without Effusion
Tuberculosis
Pleurodynia, Bronholm's
Disease
Pneumonia, All Types
Pneumothorax,
Spontaneous or Tension
Poisoning
Food
Blood
Poliomyelitis, Acute
Polyarteritis Nodosa
Polycythemia Vera
Polycystic Ovaries
Polymyalgia Rheumatic
Polymyositis
Polyp
Anal or Rectal
Cervical
Nasal
Porphyria
Positive Conversion of
T.B. Skin Test
Postmaturity
Pre-eclampsia (P.E.T.)
Pregnancy
Abnormality Bony Pelvis
February 2014
Code
301
301
033
734
460
605
451
300
614
646
685
4 - 58
641
511
012
074
486
512
005
038
045
446
239
256
725
710
569
219
471
277
010
766
642
653
Version 1.0
Claims Submission
Alpha
Diagnosis
Premature Labour
Prematurity
Premenstrual Tension
Presbyopia
Presenile Dementia
Problems
Prognathism
Prolapse
Prolonged Labour
Prostatitis
Pruritic (Itchy)
Condition,
Other
Pruritus Ani
Psoriasis
Psychosis
February 2014
Description
Anemia of
Ectopic
Foetal Distress
Multiple
Other complications (e.g., Vulvitis, Vaginitis,
Cervicitis, Pyelitis)
Premature Rupture of Membranes
Prolonged Pregnancy (post dates/post maturity
pregnancy)
Cystitis
Uncomplicated
Code
646
633
656
651
646
658
645
646
650
644
765
625
367
290
Aged Parent(s)
900
Economic
897
Educational
902
Family Disruption, Divorce
901
Illegitimacy
903
In-laws
900
Legal Problems, Litigation, Imprisonment
906
Occupational, Unemployment, Difficulty at Work 905
Parent/child (e.g., child-abuse, battered child,
899
child neglect)
Social Maladjustment
904
Other problems of social adjustment
909
524
Rectal
569
Umbilical Cord
762
Uterine
618
662
601
698
698
696
291
Alcoholic
4 - 59
Version 1.0
Claims Submission
Alpha
Diagnosis
Description
Childhood
Drug
Korsakov's
Manic Depressive
Other
Psychosomatic
Disturbances
Pterygium
Ptosis, Eyelid
Pulmonary Tuberculosis
Pulmonary Embolism,
Infarction
P.U.O. (Pyrexia of
Unknown
Origin)
Purpura
Pyelitis
372
374
011
415
780
During Pregnancy
Pyelonephritis, Acute or
Chronic
Pyoderma
Pyogenic Arthritis
Pyogenic Granuloma
Quadriplegia
Rabies
Rash
Raynaud's Disease
Rectal Stricture,
Prolapse, Bleeding
Rectocele
Recurrent Uveitis
Refraction and
Accommodation
Disorder
Renal Colic
Renal Failure Acute
Renal Failure Chronic
Respiratory Distress
Syndrome
Retained Placenta
February 2014
Code
299
292
291
296
298
306
287
590
634
590
686
711
686
349
079
691
443
569
618
972
367
788
584
585
769
667
4 - 60
Version 1.0
Claims Submission
Alpha
Diagnosis
Retinal Detachment
Retinitis
Retrognathism
Retroversion of Uterus
Rheumatic Fever With
Endocarditis,
Myocarditis or
Pericarditis
Rheumatic Fever
Without
Endocarditis,
Myocarditis or
Pericarditis
Rheumatic Heart
Disease
Rheumatism, Muscular
Rhinitis, Allergic
Ringworm
Description
390
Other
398
Scalp, Beard, Foot
Other
729
477
110
117
057
056
Roseola
Rubella (German
Measles)
Rubeoloa (Measles)
Salivary Gland, Diseases
of
Salmonella Infections
Salpingitis
Acute, or chronic (fallopian tube)
Eustachian
Sarcoidosis
Scabies
Scar, Scarring
Scarlet Fever
Schizoid Personality
Disorder
Schizophrenia
Sciatica
Scleroderma
Localized
Generalized
Scoliosis
Sebaceous Cyst
February 2014
Code
361
363
524
621
391
4 - 61
055
527
003
614
384
135
133
709
034
301
295
724
701
710
737
706
Version 1.0
Claims Submission
Alpha
Diagnosis
Seborrheic Dermatitis
Seminal Vesiculitis
Senescence
Senile Dementia
Senility
Septal Defect, Atrial or
Ventricular
Septicemia
Sexual Deviations
Sexual Dysfunction
Shingles
Shock
Shortness of Breath
Silicosis
Sinusitis Acute
Sinusitis Chronic
Skin, Dry
Sleep Disorders
Social Adjustment
Problem
Social Maladjustment
Spasms, Muscle
Spastic Colon
Spermatocele
Spina Bifida With or
Without
Hydrocephalus
Spondylitis
Spondyloarthropathies
Spondylosis
Sprains - See Strains
Sprue
Staphlococcal Infection
Stasis Ulcer
Stein-Leventhal
Syndrome
Stenosis
February 2014
Description
Other than those individually specified in this
list
Code
690
608
797
290
797
745
038
302
306
053
785
786
502
461
473
701
307
909
904
728
564
608
741
Ankylosing
Sero-Negative
720
721
718
579
038
454
256
Esophagus
Mitral
Pulmonary Artery
Vagina
4 - 62
530
394
747
623
Version 1.0
Claims Submission
Alpha
Diagnosis
Sterilization Advice
Sterility
Still's Disease
Sting, Bee Or Wasp
Stomal Ulcer
Stomatitis
Stone (Calculus)
Strabismus
Strains, Sprains and
Other
Trauma
Streptococcal Sore
Throat
Stress Incontinence
Stricture
Stroke, C.V.A.
Stuttering
Stye
Sudden Death, Cause
Unknown
Suicide, Attempted
Description
In Kidney or Ureter
(Cholelithiasis) with or without Cholecystitis
Ankle, Foot, Toes
Coccyx
Knee, Leg
Neck
Shoulder, Upper Arm
Wrist, Hand, Fingers
Other
Anal or Rectal
Esophagus
Urethral
Vagina
Chemicals
Drugs
Tendencies
Trauma
Sweating, Excessive
Swine Flu
Syncope
Synovitis
Syphilis, All Sites and
Stages
Syringomyelia
February 2014
Code
895
628
714
989
534
528
592
574
378
845
847
844
847
840
842
848
034
625
569
530
598
623
436
307
373
798
989
977
300
959
799
487
785
727
097
349
4 - 63
Version 1.0
Claims Submission
Alpha
Diagnosis
Tachycardia
Description
Not yet diagnosed
Paroxysmal
Taenia
Tapeworm Infestation,
All Types
Tay-Sachs Disease
Teeth, Other Diseases of
Hard Tissues
Teeth and Supporting
Structures
Other Conditions
Teething
Temporomandibular
Joint
Disorders
Tenosynovitis
Testicular Dysfunction
Tetanus
Tetralogy of Fallot
Thalassemia
Threatened Labour
Thrombocytopenia
Thrombophlebitis
Thrombosis
Thrombosis of Portal
Vein
Thrush
Thyroiditis
Thyrotoxicosis
Tic Douloureux
Tics
Tinnitus
Tobacco Abuse
Tongue, Other
Conditions of Tonsillitis
February 2014
Code
785
427
123
123
330
521
525
525
524
Post Partum
Cerebral
Coronary
727
257
037
745
282
644
287
451
671
436
410
452
112
245
242
350
307
388
305
529
463
Acute
4 - 64
Version 1.0
Claims Submission
Alpha
Diagnosis
Tonsils And/or
Adenoids,
Hypertrophy or Chronic
Infection
Torsion of Cord or
Testis
Torticollis (Wry Neck)
Toxaemia of Pregnancy
Toxoplasmosis
Tracheitis, Acute
Transient Cerebral
Ischaemia
Transportation of Great
Vessels
Traumatic Arthritis
Trichomonas Infection
Tuberculosis
Turner's Syndrome
Typhoid Fever,
Paratyphoid
Ulcer
Description
608
739
642
130
464
435
745
Bones and Joints
Other Organs
Pleurisy - with or without effusion
Pulmonsary
Recent positive conversion of T.B. skin
Respiratory
Test
Aphthous
Corneal
Decubitus
Duodenal with or without haemorrhage or
perforation
Esophagus
Gastric with or without haemorrhage or
perforation
Stasis
Stomal, Gastrojejunal
Hunner's
Undescended Testicle
Unemployment
Problems
February 2014
Code
474
4 - 65
716
131
015
017
012
011
012
010
758
002
528
370
707
532
530
531
454
534
595
608
905
Version 1.0
Claims Submission
Alpha
Diagnosis
Unusual Position Of
Fetus
Upper Respiratory
Infection
Urachal Cyst
Uremia
Urethral Stricture
Urethritis, Non-specific
Urethrocele
Urinary Retention
Urticaria, Allergic
Uterine
Vaginitis
Varicose Veins
Vasculitis
Vaso Vagal Attack
Ventricular Flutter,
Fibrillation
Verruca
Vertigo
Vesiculitis, Seminal
Vestibulitis
Vincent's Angina
Viremia
Visual Field Defects
Vitamin and Other
Nutritional Deficiencies
Volvulus
Vomiting
Vomiting, as a
Complication
of Pregnancy
Vulvitis
Warts
February 2014
Description
Code
652
460
Not sexually transmitted
Fibroid
Inertia
Prolapse
(Not trichomonas - see 131)
With Pregnancy
With Pregnancy
Of lower extremities, with or without ulcer
753
585
598
597
618
788
708
218
661
618
616
646
646
454
447
780
427
078
780
608
386
136
790
368
269
560
787
643
Unrelated to Pregnancy
With Pregnancy
All Types
Seborrheic
4 - 66
616
646
078
216
Version 1.0
Claims Submission
Alpha
Diagnosis
Description
Venereal, Other Disorders
Wasp Sting
Wax in Ear
Well Vision Care
Whiplash
Whooping Cough
Wry Neck (Torticollis)
February 2014
4 - 67
Code
629
989
388
917
847
033
739
Version 1.0
Claims Submission
Other Diseases or Disorders - Not Specified Elsewhere
Diagnosis
Adrenal Gland
Amino Acid Metabolism
Arteries
Bacterial Diseases
Behaviour of Childhood
and
Adolescence
Bile Ducts
Blood
Bone and Cartilage
Breast
Circulatory System
Conduction
Conjunctiva
Connective Tissue
Cranial Nerves
Depressive
Digestive System
Duodenum
Ear
Endocrine
Eustachian Tube
Eye
Eyelid
Facial Nerves
Fetus or Newborn
Gallbladder
General Symptoms
Genital Organs, Female
Genital Organs, Male
Heart Disease
Helminthiases
Immunity
Infective Disease
Injuries
Intervertebral Disc
Intestine
February 2014
Description
Other
Not elsewhere classified
Signs and symptoms not yet diagnosed
Signs and symptoms not yet diagnosed
4 - 68
Code
255
270
447
040
313
576
289
733
611
459
426
759
372
739
352
311
787
537
388
259
381
379
374
351
779
576
799
629
608
788
429
128
279
136
959
722
569
Version 1.0
Claims Submission
Other Diseases or Disorders - Not Specified Elsewhere
Diagnosis
Intestines
Kidney
Lipoid Metabolism
Liver
Marrow
Mastoid
Menstruation
Metabolic Disorders
Mycoses
Myoneural
Nervous System, Central
Newborn
Non-psychotic
Pancreas
Parasitic Diseases
Personality Disorders
Pituitary Gland
Psychoses
Refraction and
Accommodation
Respiratory System
Skin and Subcutaneous
Tissue
Description
Other vascular conditions
Not elsewhere classified
Signs and Symptoms not yet diagnosed
Other disorders
Other itchy conditions
Other local infections
Sleep
Spleen
Stomach
Teeth and Supporting
Structures
Trauma
Ureter
Urinary Tract
Uterus
Venereal
Viral Disease
Of central nervous system, non-arthropodborne
Well Baby Care
February 2014
Code
557
593
272
573
289
388
626
277
739
117
358
349
779
311
577
136
301
253
298
367
519
786
709
698
686
307
289
537
525
959
593
599
621
099
079
049
916
4 - 69
Version 1.0
Claims Submission
Infections and Parasitic Diseases
Diagnosis
Intestinal Infectious
Diseases
Tuberculosis
Other Bacterial Diseases
Human
Immunodeficiency Virus
(HIV) Infection
Non-arthropod-borne
Viral Diseases of Central
Nervous System
Viral Diseases
Accompanied
by Rash
Other Viral Diseases
February 2014
Description
Typhoid and paratyphoid fevers
Other salmonella infections
Food poisoning
Amoebiasis, amoebic dysentery
Diarrhea, gastro-enteritis, viral gastro-enteritis
Primary tuberculous infection, including recent
positive TB skin test conversion
Pulmonary tuberculosis
Other respiratory tuberculosis, tuberculous
pleurisy with or without effusion
Tuberculosis of bones and joints
Tuberculosis of other organs
Brucellosis
Leprosy (Hansen's Disease)
Diphtheria
Whooping cough, pertussis
Streptococcal sore throat, scarlet fever
Erysipelas
Meningococcal infection or meningitis
Tetanus
Septicemia, blood poisoning
Actinomycotic infections
Other bacterial diseases
AIDS
AIDS-related complex (ARC)
Other human immunodeficiency virus infection
Acute poliomyelitis
Meningitis due to enterovirus
Other non-arthropod-borne viral diseases of
central nervous system
Chickenpox
Herpes zoster, shingles
Herpes simplex, cold sore
Measles
German measles, rubella
Other viral disorders accompanied by rash
(e.g., roseola)
Mosquito-borne viral encephalitis
4 - 70
Code
002
003
005
006
009
010
011
012
015
017
023
030
032
033
034
035
036
037
038
039
040
042
043
044
045
047
049
052
053
054
055
056
057
062
Version 1.0
Claims Submission
Infections and Parasitic Diseases
Diagnosis
Venereal Diseases
Mycoses
Helminthiases
Other Infectious and
Parasitic Diseases
Description
Other arthropod-borne viral diseases
Viral hepatitis
Mumps
Diseases due to Coxsackie virus: pleurodynia,
myocarditis
Infectious mononucleosis, glandular fever
Warts
Other viral diseases
Syphilis - all sites and stages
Gonococcal infections
Other venereal diseases (e.g., herpes
genitalis)
Diagnostic code 100 is for internal use only
and
should be used when it is requested that the
service or diagnosis on the incoming claim be
suppressed from verification. The usage of the
code is monitored
Ringworm of scalp, beard, or foot
Candidiasis, monilia infection - all sites, thrush
Histoplasmosis
Other mycoses
Echinococcosis, hydadid cyst - all sites
Taenia or tapeworm infestation - all types
Pinworm infestation
Other helminthiases
Toxoplasmosis
Trichomonas infection
Head or body lice, pediculosis
Scabies, acariasis
Sarcoidosis
Other infectious or parasitic diseases
Code
066
070
072
074
Description
Lip
Tongue
Major salivary glands
Gum
Floor of mouth
Code
140
141
142
143
144
075
078
079
097
098
099
100
110
112
115
117
122
123
127
128
130
131
132
133
135
136
Neoplasms
Diagnosis
Malignant Neoplasms
February 2014
4 - 71
Version 1.0
Claims Submission
Neoplasms
Diagnosis
February 2014
Description
Other and unspecified parts of mouth
Oropharynx
Nasopharynx
Hypopharynx
Other and ill-defined sites within the lip, oral
cavity, and pharynx
Esophagus
Stomach
Small intestine, including duodenum
Large intestine - excluding rectum
Rectum, rectosigmoid and anus
Primary malignancy of liver (not secondary
spread or metastatic disease)
Gallbladder and extra hepatic bile ducts
Pancreas
Retroperitoneum and peritoneum
Other and ill-defined sites within the digestive
organs and peritoneum
Nasal cavities, middle ear, and accessory
sinuses
Larynx, trachea
Bronchus, lung
Pleura
Thymus, heart, and mediastinum
Other sites within the respiratory system and
intrathoracic organs
Bone
Melanoma of skin
Other skin malignancies
Female breast
Male breast
Uterus, part unspecified
Cervix
Placenta
Body of uterus
Ovary, fallopian tube, broad ligament
Vagina, vulva, other female genital organs
Prostate
Testis
4 - 72
Code
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
170
171
172
173
174
175
179
180
181
182
183
184
185
186
Version 1.0
Claims Submission
Neoplasms
Diagnosis
Benign Neoplasms
February 2014
Description
Other male genital organs
Bladder
Kidney, other urinary organs
Eye
Brain
Cranial nerves, spinal cord, other parts of
nervous system
Thyroid
Other endocrine glands and related structures
Other ill-defined sites
Secondary neoplasm of lymph nodes
Secondary neoplasm of respiratory and
digestive systems
Metastatic or secondary malignant neoplasm,
carcinomatosis
Other malignant neoplasms
Lymphosarcoma, reticulosarcoma
Hodgkin's disease
Other malignant neoplasms of lymphoid and
histiocytic tissue
Multiple myeloma, plasma cell leukemia
Lymphoid leukemia (including lymphatic and
histiocytic leukemia)
Myeloid leukemia (including granulocytic and
myelogenous leukemia)
Monocytic leukemia
Other specified leukemia
Other types of leukemia
Lip, oral cavity, pharynx
Other parts of digestive system, peritoneum
Respiratory and intra-thoracic organs
Bone, cartilage
Lipoma
Skin (e.g., pigmented naevus, dermatofibroma)
Breast
Uterine fibroid, leiomyoma
Other benign neoplasms of uterus (e.g.,
cervical polyp)
Ovary (e.g., ovarian cyst)
4 - 73
Code
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
210
211
212
213
214
215
216
217
218
219
220
Version 1.0
Claims Submission
Neoplasms
Diagnosis
Carcinoma in Situ
Neoplasms of Uncertain
Behavior
Description
Other benign neoplasms of female genital
organs
Benign neoplasms of male genital organs
Kidney, ureter, bladder
Eye
Brain, spinal cord, peripheral nerves
Thyroid (e.g., adenoma or cystadenoma)
Other endocrine glands and related structures
Haemangioma and lymphangiomax
Other benign neoplasms
Digestive organs
Respiratory system
Skin
Breast and genito-urinary system
Other
Digestive and respiratory systems
Genitourinary organs
Endocrine glands and nervous system
Other and unspecified sites and tissues
Unspecified neoplasms (e.g., polycythemia
vera)
Code
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
Endocrine, Nutritional and Metabolic Diseases and Immunity
Disorders
Diagnosis
Endocrine Glands
February 2014
Description
Simple thyroid goitre
Nontoxic nodular goitre
Hyperthyroidism, thyrotoxicosis, exophthalmic
goitre
Hypothyroidism - congenital (i.e., cretinism)
Hypothyroidism - acquired (i.e., myxedema)
Thyroiditis
Pre-diabetes
Diabetes mellitus, including complications
Other disorders of pancreatic internal
secretions (e.g., insulinoma neo-natal
hypoglycemia, Zollinger -Ellison syndrome)
Parathyroid gland disorders (e.g.,
hyperparathyroidism, hypoparathyroidism)
4 - 74
Code
240
241
242
243
244
245
249
250
251
252
Version 1.0
Claims Submission
Endocrine, Nutritional and Metabolic Diseases and Immunity
Disorders
Diagnosis
Nutritional and Metabolic
Disorders
Immunity Disorders
Description
Pituitary gland disorders (e.g., acromegaly,
dwarfism, diabetes insipidus)
Adrenal gland disorders (e.g., Cushing's
syndrome, hyperaldosteronism, Conn's
syndrome, adrenogenital syndrome, Addison's
disease)
Ovarian dysfunction (e.g., ovarian failure,
polycystic ovaries, Stein-Leventhal syndrome)
Testicular dysfunction
Other endocrine disorders
Unspecified malnutrition
Vitamin and other nutritional deficiencies
Disorders of amino-acid metabolism (e.g.,
cystinuria, Fanconi syndrome)
Disorders of lipoid metabolism (e.g.,
hypercholesterolemia, lipoprotein disorders)
Gout
Other metabolic disorders
Obesity
Hypogammaglobulinemia,
agammaglobulinemia, other immunity
disorders
Code
253
255
256
257
259
263
269
270
272
274
277
278
279
Diseases of Blood And Blood-Forming Organs
Diagnosis
Diseases of Blood and
Blood-Forming Organs
February 2014
Description
Iron deficiency anaemia
Pernicious anaemia
Hereditary hemolytic anaemia (e.g.,
thalassemia, sickle-cell anaemia)
Acquired hemolytic anaemia, excluding
hemolytic disease of newborn
Aplastic anaemia
Other anaemias
Coagulation defects (e.g., hemophilia, other
factor deficiencies)
Purpura, thrombocytopenia, other hemorrhagic
conditions
Neutropenia, acranulocytosis, eosinophilia
Other diseases of blood, marrow, spleen
4 - 75
Code
280
281
282
283
284
285
286
287
288
289
Version 1.0
Claims Submission
Mental Disorders
Diagnosis
Psychoses
Neuroses and
Neuroses and
(Continued)
Description
Senile dementia, presenile dementia
Alcoholic psychosis, delirium tremens,
Korsakov's psychosis
Drug psychosis
Schizophrenia
Manic depressive psychosis, involutional
melancholia
Paranoid states
Other psychoses
Childhood psychoses (e.g., autism)
Anxiety neurosis, hysteria, neurasthenia,
obsessive compulsive neurosis, reactive
depression
Personality disorders (e.g., paranoid
personality, schizoid personality, obsessive
compulsive personality)
Sexual deviations
Alcoholism
Drug dependence, drug addiction
Tobacco abuse
Psychosomatic disturbances
Habit spasms, tics, stuttering, tension
headaches, anorexia nervosa, sleep disorders,
enuresis
Adjustment reaction
Depressive or other non-psychotic disorders,
not elsewhere classified
Behaviour disorders of childhood and
adolescence
Hyperkinetic syndrome of childhood
Specified delays in development (e.g.,
dyslexia, dyslalia, motor retardation)
Mental retardation
Code
290
291
292
295
296
297
298
299
300
301
302
303
304
305
306
307
309
311
313
314
315
319
Diseases of the Nervous System and Sense Organs
Diagnosis
Central Nervous System
February 2014
Description
Bacterial meningitis
Meningitis due to other organisms
Encephalitis, encephalomyelitis
4 - 76
Code
320
321
323
Version 1.0
Claims Submission
Diagnosis
Peripheral Nervous
System
Eye
February 2014
Description
Tay-Sachs disease
Other cerebral degenerations
Parkinson's disease
Multiple sclerosis
Cerebral palsy
Epilepsy
Migraine
Other diseases of central nervous system
(e.g., brain abscess, narcolepsy, motor neuron
disease, syringomyelia)
Trigeminal neuralgia, tic douloureux
Bell's palsy, facial nerve disorders
Disorders of other cranial nerves
Idiopathic peripheral neuritis
Myoneural disorders (e.g., myasthenia gravis)
Muscular dystrophies
Aphakia
Retinal detachment
Hypertensive retinopathy and other retinal
diseases not specifically listed
Chorioretinitis
Iritis
Glaucoma
Cataract, excludes diabetic or congenital
Myopia, astigmatism (except for the specific
conditions defined by diagnostic code 371),
presbyopia and other disorders of refraction
and accommodation
Amblyopia, visual field defects
Blindness and low vision
Keratitis, corneal ulcer
High Myopia greater than 9 diopters; Irregular
Astigmatism resulting from corneal grafting or
corneal scarring from diseases
Conjunctiva disorders (e.g., conjunctivitis,
pterygium)
Blepharitis, chalazion, stye
Other eyelid disorders (e.g., entropion,
ectropion, ptosis)
Dacryocystitis, obstruction of lacrimal duct
4 - 77
Code
330
331
332
340
343
345
346
349
350
351
352
356
358
359
360
361
362
363
364
365
366
367
368
369
370
371
372
373
374
375
Version 1.0
Claims Submission
Diagnosis
Ear and Mastoid
Signs and Symptoms
Not Yet Diagnosed
Description
Keratoconus
Optic neuritis
Strabismus
Other disorders of the eye
Otitis externa
Serous otitis media, eustachian tube disorders
Suppurative otitis media
Mastoiditis
Perforation of tympanic membrane
Meniere's disease, labyrinthitis
Otosclerosis
Wax or cerumen in ear, other disorders of ear
and mastoid, tinnitus
Deafness
Convulsions, ataxia, vertigo, headache, except
tension headache and migraine
Code
376
377
378
379
380
381
382
383
384
386
387
388
389
780
Diseases of the Circulatory System
Diagnosis
Rheumatic Fever and
Rheumatic Heart
Disease
Hypertensive Disease
Ischaemic and Other
Forms
of Heart Disease
Ischaemic and Other
Forms of Heart
Disease
February 2014
Description
Rheumatic fever without endocarditis,
myocarditis or pericarditis
Rheumatic fever with endocarditis, myocarditis,
or pericarditis
Chorea
Mitral stenosis, mitral insufficiency
Other rheumatic heart disease
Essential, benign hypertension
Hypertensive heart disease
Hypertensive renal disease
Acute myocardial infarction
Old myocardial infarction, chronic coronary artery
disease of arteriosclerotic heart disease, without
symptoms
Acute coronary insufficiency, angina pectoris,
acute ischaemic heart disease
Pulmonary embolism, pulmonary infarction
Heart blocks, other conduction disorders
Paroxysmal tachycardia, atrial or ventricular
flutter
or fibrillation, cardiac arrest, other arrythmias
4 - 78
Code
390
391
392
394
398
401
402
403
410
412
413
415
426
427
Version 1.0
Claims Submission
Diseases of the Circulatory System
Diagnosis
Cerebrovascular
Disease
Diseases of Arteries
Diseases of Veins and
Lyphatics
Signs and Symptoms
Not Yet Diagnosed
Description
Congestive heart failure
All other forms of heart disease
Intracranial Haemorrhage
Transient cerebral ischaemia
Acute cerebrovascular accident, C.V.A., stroke
Chronic arteriosclerotic cerebrovascular disease,
hypertensive encephalopathy
Generalized arteriosclerosis, atherosclerosis
Aortic aneurysm (non-syphilitic)
Raynaud's disease, Buerger's disease, peripheral
vascular disease, intermittent claudication
Polyarteritis nodosa, temporal arteritis
Other disorders of arteries
Phlebitis, thrombophlebitis
Portal vein thrombosis
Varicose veins of lower extremities with or
without ulcer
Haemorrhoids
Lymphangitis, lymphedema
Other disorders of circulatory system
Chest pain, tachycardia, syncope, shock, edema,
masses
Code
428
429
432
435
436
437
440
441
443
446
447
451
452
454
455
457
459
785
Diseases of the Respiratory System
Diagnosis
February 2014
Description
Acute nasopharyngitis, common cold
Acute sinusitis
Acute tonsillitis
Acute laryngitis, tracheitis, croup, epiglottis
Acute bronchitis
Deviated nasal septum
Nasal polyp
Chronic sinusitis
Hypertrophy or chronic infection of tonsils and/or
adenoids
Allergic rhinitis, hay fever
Pneumonia - all types
Influenza
Chronic bronchitis
4 - 79
Code
460
461
463
464
466
470
471
473
474
477
486
487
491
Version 1.0
Claims Submission
Diseases of the Respiratory System
Diagnosis
Signs and Symptoms
Not Yet Diagnosed
Description
Emphysema
Asthma, allergic bronchitis
Bronchiectasis
Other chronic obstructive pulmonary disease
Asbestosis
Silicosis
Pleurisy with or without effusion
Spontaneous pneumothorax, tension
pneumothorax
Pulmonary fibrosis
Atelectasis, other diseases of lung
Other diseases of respiratory system
Epistaxis, hemoptysis, cough, dyspnea, masses,
shortness of breath, hyperventilation, sleep apnea
Code
492
493
494
496
501
502
511
512
515
518
519
786
Diseases of the Digestive System
Diagnosis
Diseases of Oral Cavity,
Salivary Glands and
Jaws
Diseases of Esophagus,
Stomach and Duodenum
February 2014
Description
Dental caries, other diseases of hard tissues of
teeth (system inserted for dentists' claims)
Gingivitis, periodontal disease
Prognathism, micrognathism, macrognathism,
retrognathism, malocclusion,
temporomandibular joint disorders
Other conditions of teeth and supporting
structure
Disease of salivary glands
Stomatitis, aphthous ulcers, canker sore,
diseases of lips
Glossitis, other conditions of the tongue
Esophagitis, cardiospasm, ulcer of esophagus;
stricture, stenosis, or obstruction of esophagus
Gastric ulcer, with or without haemorrage or
perforation
Duodenal ulcer, with or without haemorrhage
or perforation
Stomal ulcer, gastrojejunal ulcer
Gastritis
Hyperchlorhydria, hypochlorhydria, dyspepsia,
indigestion
Other disorders of stomach and duodenum
4 - 80
Code
521
523
524
525
527
528
529
530
531
532
534
535
536
537
Version 1.0
Claims Submission
Diseases of the Digestive System
Diagnosis
Hernia
Other Diseases of
Intestine
and Peritoneum
Other Diseases of
Digestive System
Signs and Symptoms
Not Yet Diagnosed
Description
Inguinal hernia, with or without obstruction
hiatus hernia with obstruction
hiatus hernia without obstruction
Acute appendicitis, with or without abscess or
peritonitis
Regional enteritis, Crohn's disease
Ulcerative colitis
Mesenteric artery occlusion, other vascular
conditions of intestine
Intestinal obstruction, intussusception,
paralytic ileus, volvulus, impaction of intestine
Diverticulitis or diverticulosis of large or small
intestine
Spastic colon, irritable colon, mucous colitis,
constipation
Anal fissure, anal fistula
Abscess of anal or rectal regions
Peritonitis, with or without abscess
Anal or rectal polyp, rectal prolapse, anal or
rectal stricture, rectal bleeding, other disorders
of intestine
Cirrhosis of the liver (e.g., alcoholic cirrhosis,
biliary cirrhosis)
Other diseases of the liver
Cholelithiasis (gall stones) with or without
cholecystitis
Cholecystitis, without gall stones
Other diseases of gallbladder and biliary ducts
Diseases of pancreas
Malabsorption syndrome, sprue, celiac disease
Anorexia, nausea and vomiting, heartburn,
dysphagia, hiccough, hematemesis, jaundice,
ascites, abdominal pain, melena, masses
Code
550
552
553
540
555
556
557
560
562
564
565
566
567
569
571
573
574
575
576
577
579
787
Diseases of the Genito - Urinary System
Diagnosis
Diseases of the Urinary
System
February 2014
Description
Acute glomerulonephritis
Nephrotic Syndrome
4 - 81
Code
580
581
Version 1.0
Claims Submission
Diagnosis
Diseases of the Urinary
System (Continued)
Diseases of Male Genital
Organs
Diseases of Breast and
Female Pelvic Organs
Other Disorders of
Female Genital Tract
February 2014
Description
Acute renal failure
Chronic renal failure, uremia
Acute or chronic pyelonephritis, pyelitis,
abscess
Hydronephrosis
Stone in kidney or ureter
Other disorders of kidney or ureter
Cystitis
Non-specific urethritis (not sexually
transmitted)
Urethral stricture
Other disorders of urinary tract
Benign prostatic hypertrophy
Prostatitis
Hydrocele
Orchitis, epididymitis
Phimosis, paraphimosis
Male infertility, oligospermia, azoospermia
Seminal vesiculitis, spermatocele, torsion of
cord or testis, undescended testicle, other
disorders of male genital organs
Newborn circumcision
Cystic mastitis, chronic cystic disease, breast
cyst, fibro-adenosis of breast
Breast abscess, gynecomastia, hypertrophy,
other disorders of breast
Acute or chronic salpingitis or oophoritis or
abscess, pelvic inflammatory disease
Acute or chronic endometritis
Cervicitis, vaginitis, cyst or abscess of
Bartholin's gland, vulvitis
Endometriosis
Cystocele, rectocele, urethrocele, enterocele,
uterine prolapse
Retroversion of uterus, endometrial
hyperplasia, other disorders of uteru
Cervical erosion, cervical dysplasia
Stricture or stenosis of vagina
Dyspareunia, dysmenorrhea, premenstrual
tension, stress incontinence
4 - 82
Code
584
585
590
591
592
593
595
597
598
599
600
601
603
604
605
606
608
609
610
611
614
615
616
617
618
621
622
623
625
Version 1.0
Claims Submission
Diagnosis
Other Disorders of
Female Genital Tract
(Continued)
Signs and Symptoms
Not Yet Diagnosed
Description
Disorders of menstruation
Menopause, post-menopausal bleeding
Infertility
Other disorders of female genital organs
Code
626
627
628
629
Chorioretinitis
636
Renal colic, urinary retention, nocturia, masses 788
Complications of Pregnancy, Childbirth and the Puerperium
Diagnosis
February 2014
Description
Missed abortion
Ectopic pregnancy
Incomplete abortion, complete abortion
Therapeutic abortion
Threatened abortion, haemorrhage in early
pregnancy
Abruptio placentae, placenta praevia
Pre-eclampsia, eclampsia, toxaemia
Vomiting, hyperemesis gravidarum
False labour, threatened labour
Prolonged pregnancy
Other complications of pregnancy (e.g.,
vulvitis, vaginitis, cervicitis, pyelitis, cystitis)
Normal delivery, uncomplicated pregnancy
Multiple pregnancy
Unusual position of fetus, malpresentation
Cephalo-pelvic disproportion
Foetal distress
Premature rupture of membrane
Obstructed labour
Uterine inertia
Prolonged labour
Perineal lacerations
Post-Partum haemorrhage
Retained placenta
Delivery with other complications
Post-Partum thrombophlebitis
Post-Partum mastitis or nipple infection
4 - 83
Code
632
633
634
635
640
641
642
643
644
645
646
650
651
652
653
656
658
660
661
662
664
666
667
669
671
675
Version 1.0
Claims Submission
Complications of Pregnancy, Childbirth and the Puerperium
Diagnosis
Description
Post-Partum pulmonary
Code
677
Diseases of the Skin and Subcutaneous Tissue
Diagnosis
Infections
Other Inflammatory
Conditions
Other Diseases of Skin
and Subcutaneous Tissue
Description
Boil, carbuncle, furunculosis
Cellulitis, abscess
Acute lymphadenitis
Impetigo
Pilonidal cyst or abscess
Pyoderma, pyogenic granuloma, other local
infections
Seborrheic dermatitis
Eczema, atopic dermatitis, neurodermatitis
Contact dermatitis
Erythema multiforme, erythema nodosum,
acne, rosacea, lupus erythematosus, intertrigo
Psoriasis
Pruritus ani, other itchy conditions
Corns, calluses
Hyperkeratosis, scleroderma, keloid
Ingrown nail, onychogryposis
Alopecia
Acne, acne vulgaris, sebaceous cyst
Debcubitus ulcer, bed sore
Allergic urticaria
Other disorders of skin and subcutaneous
tissue
Code
680
682
683
684
685
686
690
691
692
695
696
698
700
701
703
704
706
707
708
709
Diseases of Muscoloskeletal System and Connective Tissue
Diagnosis
February 2014
Description
Desseminated lupus erythematosus,
generalized scleroderma, dermatomyositis,
polymostitis
Pyogenic arthritis
Rheumatoid arthritis, Still's disease
Osteoarthritis
Traumatic arthritis
Joint derangement, recurrent dislocation,
ankylosis, meniscus or cartilage tear, loose
body in joint
4 - 84
Code
710
711
714
715
716
718
Version 1.0
Claims Submission
Diseases of Muscoloskeletal System and Connective Tissue
Diagnosis
Signs and Symptoms
Not Yet Diagnosed
Description
Ankylosing spondylitis
Sero- negative Spondyloarthropathies
Intervertebral disc disorders
Lumbar strain, lumbago, coccydynia, sciatica
Synovitis, tenosynovitis, bursitis, bunion,
ganglion
Dupuytren's contracture
Fibrositis, myositis, muscular rheumatism
Osteomyelitis
Osteitis deformans, Paget's disease of bone
Osteochondritis, Legg-Perthes disease,
Osgood-Schlatter disease, osteochondritis
dissecans
Osteoporosis, spontaneous fracture, other
disorders of bone and cartilage
Flat foot, pes planus
Hallux valgus, hallux varus, hammer toe
Scoliosis, kyphosis, lordosis
Other diseases of musculoskeletal system and
connective tissue
Leg cramps, leg pain, muscle pain, joint pain,
arthralgia, joint swelling, masses
Code
720
721
722
724
727
Description
Spina bifida, with or without hydrocephalus,
meningocele, meningomyelocele
Hydrocephalus
Congenital anomalies of eye
Congenital anomalies of ear, face, and neck
Transposition of great vessels, tetralogy of
Fallot, ventricular septal defect, atrial septal
defect
Other congenital anomalies of heart
Patent ductus arteriosus, coarctation of aorta,
pulmonary artery stenosis, other anomalies of
circulatory system
Congenital anomalies of nose and respiratory
system
Cleft palate, cleft lip
Code
741
728
729
730
731
732
733
734
735
737
739
781
Diagnosis
February 2014
4 - 85
742
743
744
745
746
747
748
749
Version 1.0
Claims Submission
Diagnosis
Description
Other congenital anomalies of mouth
esophagus, stomach and pylorus
Digestive system
Genital organs
Urinary system
Club foot
Other congenital anomalies of limbs
Other musculoskeletal anomalies
Chromosomal anomalies (e.g., Down's
syndrome, other autosomal anomalies,
Klinefelter's syndrome, Turner's syndrome,
other anomalies of sex chromosomes)
Other congenital anomalies
Code
750
751
752
753
754
755
756
758
759
Perinatal Morbidity and Mortality
Diagnosis
Description
Compression of umbilical cord, prolapsed cord
Due to complications of labour or delivery
Prematurity, low-birthweight infant
Postmaturity, high-birthweight infant
Birth trauma
Hyaline membrane disease, respiratory
distress syndrome
Hemolytic disease of newborn
Perinatal disorders of digestive system
Other conditions of fetus or newborn
Code
762
763
765
766
767
769
773
777
779
Symptoms, Signs and Ill-Defined Conditions
Diagnosis
Non-specific Abnormal
Findings
February 2014
Description
Non-specific findings on examination of blood
Non-specific findings on examination of urine
Chronic fatigue symdrome
Other non-specific abnormal findings
Senility, senescence
Sudden death, cause unknown
Other ill-defined conditions
4 - 86
Code
790
791
795
796
797
798
799
Version 1.0
Claims Submission
Accidents, Poisonings and Violence
Diagnosis
Fractures and Fracturedislocations
Fractures and Fracturedislocations (Continued)
Dislocations
Sprains, Strains and
Other Trauma
February 2014
Description
Facial bones
Skull
Vertebral column - without spinal cord damage
Vertebral column - with spinal cord damage
Ribs
Pelvis
Clavicle
Humerus
Radius and/or ulna
Carpal bones
Metacarpals
Phalanges - foot or hand
Femur
Tibia and/or fibula
Ankle
Other fractures
Shoulder
Elbow
Finger
Other dislocations
Shoulder, upper arm
Wrist, hand, fingers
Knee, leg
Ankle, foot, toes
Neck, low back, coccyx
Other sprains and strains
Concussion
Other head injuries
Internal injuries to organ(s)
Lacerations, open wounds - except limbs
Lacerations, open wounds, traumatic
amputations upper limb(s)
Lacerations, open wounds, traumatic
amputations - lower limb(s)
Automated Visual Field (AVF) test
Abrasions, bruises, contusions and other
superficial injury including non-venomous
bites
Foreign body in eye, or other tissues
Burns - thermal or chemical
4 - 87
Code
802
803
805
806
807
808
810
812
813
814
815
816
821
823
824
829
831
832
834
839
840
842
844
845
847
848
850
854
869
879
884
894
918
919
930
949
Version 1.0
Claims Submission
Accidents, Poisonings and Violence
Diagnosis
Adverse Effects
Description
Other injuries or trauma
Of drugs and medications - including allergy,
overdose, reactions
Of other chemicals (e.g., lead, pesticides, and
venomous bites)
Of physical factors (e.g., heat, cold, frostbite,
pressure)
Of surgical and medical care (e.g., wound
infection, wound disruption, other iatrogenic
disease)
Code
959
977
989
994
998
Supplementary Classifications
Diagnosis
Family Planning
Immunization
Social, Marital and Family
Problems
Other
February 2014
Description
Family planning, contraceptive advice, advice
on sterilization or abortion
Immunization - all types
Pentavalent (DPT POLIO/ACT HIB)
DPT Polio
DT
MMR (Measles, Mumps, Rubella)
Hepatitis B
TD Polio
TD (Adults and aged 7 years and older)
Influenza
Pneumococcal
Other Immunization – Not Defined
Economic problems
Marital difficulties
Parent-child problems (e.g., child-abuse,
battered child, child neglect)
Problems with aged parents or in-laws
Family disruption, divorce
Educational problems
Illegitimacy
Social maladjustment
Occupational problems, unemployment,
difficulty at work
Legal problems, litigation, imprisonment
Other problems of social adjustment
Well baby care
4 - 88
Code
895
896
960
961
962
963
964
965
966
967
968
969
897
898
899
900
901
902
903
904
905
906
909
916
Version 1.0
Claims Submission
Supplementary Classifications
Diagnosis
Description
Annual health examination adolescent/adult
Well Vision Care
Code
917
Physiotherapy
Diagnosis
Operations on the
Other Acceptable
Diagnosis
Common Diagnostic
Codes
Arthritis
February 2014
Description
Code
Osteotomy
893
Excision Bunion
894
Excision of Bone Partial
897
Excision of Bone Complete (e.g.,
898
Patellectomy)
Excision or Destruction of Intervertebral Disc
923
Excision of Semilunar Cartilage of Knee
Synovectomy
924
Spinal Fusion
930
Arthrodesis of Foot and Ankle
931
Arthrodesis of Other Joints
932
Arthroplasty of Foot and Toe
933
Arthroplasty of Knee and Ankle (e.g., Hauser
934
Repair)
Total Hip Replacement
935
Other Arthroplasty of Hip
936
Incision of Muscle, Tendon, Fascia, ................... 940
Division of Muscle, Tendon, and Fascia of
941
Hand
Suture of Muscle, Tendon, and Fascia of Hand 944
Transplantation of Muscle and Tendon of Hand 945
Gait Training or CrutchWalking Instruction
072
(acceptable for a 1 visit treatment only)
Perceptual Motor Testing or Perceptual Motor
070
Assessment of Dysfunction
Prenatal Care
970
Post-Partum Observation
971
Osteo-degenerative
Cervical
Gouty
Rheumatic
Non-specified Acute
Non-specified Chronic
7159
7210
7120
7149
7169
7150
4 - 89
Version 1.0
Claims Submission
Physiotherapy
Diagnosis
Bells Palsy
Bursitis
Calcaneal
Calcium
Capsulitis
Cervical Disc Disease
Cervical Strain
Chest Disease
Chondromalacia
Compression Fracture Cervical
Contusion Knee
Dislocated Shoulder
Epicondylitis
Fibrositis
Frozen Shoulder
Fracture
Gout
Hamstring - Tendon
Headache
Injury
Description
Spur
Bone
Bursa
Joint
Ankle (closed)
Humerus (unspecified)
Leg
Vertebra
Wrist
Elbow
Shoulder
Kyphosis (acquired)
Lumbago
Lumbar Disc Disease
(degenerative)
Lumbar Strain
Lymphedema
Muscle Spasm
Muscle Strain
Myositis Plain and
Trauma
Neuralgia (unspecified)
Pagets Disease
February 2014
Code
3510
7310
7267
7269
7278
7198
7260
7224
8470
5199
7177
7220
9241
8310
7263
7290
7260
8248
8122
8270
8058
8140
2740
8409
7840
9593
9592
7371
7242
7251
8472
4579
7288
8489
7291
7292
7310
4 - 90
Version 1.0
Claims Submission
Physiotherapy
Diagnosis
Pain
Plantar Fascitis
Pelvis Inflammatory
Disease/
Salpingitis
PVD
Rheumatism (muscle)
Sacro-iliac Strain - Hip
Scoliosis (unspecified)
Spondylolisthese
Strained
Description
Arch
Back (posterial)
Back (low)
Neck
Ankle
Elbow
Hip
Knee and Leg
Metacarpal
Shoulder
Shin Splints
Stiff Neck
Synovitis
Temporomandibular
Strain/Sprain
Tendinitis
Tennis Elbow
Thoracic Strain
Torn Rotator Cuff
Torticollis
Trapezius Sprain
Whiplash Injury
February 2014
Code
7295
7245
7242
7231
7287
6142
4439
7290
8439
7379
7561
8450
8419
8439
8449
8421
8409
8449
7235
7270
8481
7269
7263
8471
8404
8470
8408
8470
4 - 91
Version 1.0
Claims Submission
4.14 Questions and Answers
What is the monthly cut-off for claims submission and when will I receive
payment?
Claims submissions received by the 18th of the month will be processed for
payment by the 15th of the following month. When the submission cut-off date
(18th) falls on a weekend or holiday, the deadline will be extended to the next
business day. Claims received after the 18th of the month will be processed prior
to month end if time and volumes permit.
My software program includes a field for “Manual Review Indicator”. What is
it and when would I use it?
For most claims, this field would be blank; however, if the claim requires special
consideration (e.g., two identical services billed same day), a Y indicator should
be entered in this field. If Y is used, the claim will be flagged for internal manual
reviewed and adjudication.
Supporting documentation must be sent to the ministry so that it can be
matched to the claim submission. The “Claims Flagged for Manual Review” form
(2404-84) indicates the information that is required for claims submitted with a Y
indicator. This information is to be included in the supporting documentation as
well. The form and supporting documentation should be faxed to your claims
processing office:
http://www.health.gov.on.ca/en/pro/programs/ohip/claimsoffice/default.aspx
When claims are submitted, how do I get notified of submission errors?
Claim errors are listed on your Claims Error Report which will be sent to you
within 48 hours after the file submission. Errors reported must be corrected and
resubmitted in order for payment to be made. Error reports should be retained in
order to track claims that may not appear on the next RA.
When is a claim considered stale dated?
Claims must be submitted within six months of the service date. Claims
submitted more than six months after the service has been rendered will not be
accepted for payment unless there are extenuating circumstances as defined by
ministry policy.
How do I inquire about a claim that has been overpaid/underpaid?
Inquiries regarding overpayments or underpayments should be made within one
month of the RA on which the payment appears and must be made and
resolved within six months from the service date in order for any payment
adjustment to occur. Inquiries should be submitted to your claims processing
office on a “Remittance Advice Inquiry” form (0918-84).
February 2014
4 - 92
Version 1.0
Claims Submission
The above forms are available online at:
February 2014
4 - 93
Version 1.0

4 CLAIMS SUBMISSION

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VINAYAKA MISSIONS UNIVERSITY

ProArgi-9+ and the Physicians` Desk Reference

Oracle is Invested in Your Success

RxNet is the platform to record the patient`s details for quality and

Internal Medicine. Propaedeutics as an introduction to the clinic of

Clinical essentials from the best minds in medicine

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Mad Scientists On Wheels