Program_Memos / 2003 / B-03-046

Why This Topic Matters

The memorandum affects how Medicare claims are completed and processed, especially where diagnosis information must come from the ordering or referring clinician. It is relevant for understanding documentation expectations, claims acceptance, and the operational handling of claims submitted to carriers.

Article Sections

1. Program Memorandum

   Administrative details for the memorandum, including transmittal information, subject, effective and implementation dates, and distribution instructions.

2. Attachment

   The attached CMS guidance outlining the scope of Medicare Part B diagnosis coding requirements and related provider education.

3. Background

   Context describing the regulatory and claims-processing framework discussed in the memorandum, including electronic claims standards and Medicare carrier processing considerations.

4. New Policy

   A summary of the updated claims-submission policy for diagnosis coding requirements and the handling of claims that do not meet the stated standards.

5. DMERC Suppliers

   Special instructions and operational notes for durable medical equipment regional carrier suppliers and related claim submissions.

6. Immunization Claims

   Guidance addressing claims submitted for flu and pneumonia vaccination services and related diagnosis documentation responsibilities.

7. Mammography Screening Claims

   Guidance addressing claims for screening mammography services and the documentation expected with those claims.

8. HIPAA Requirements Affect Physicians/Practitioners When a Diagnostic Test is Ordered

   Discussion of ordering/referring practitioner responsibilities when diagnostic testing or similar services are requested and billed.

9. Coding When Diagnosis is Known

   General guidance on documenting a known diagnosis for claim submission and the concept of coding to the most specific available level.

10. Coding When Diagnosis is Unknown

    General guidance for encounters where the diagnosis has not been established and the information available for documentation is limited.

11. Information for Laboratories

    Instructions for laboratory billing workflows when diagnosis information is furnished by an ordering practitioner or must be requested.

12. Information for Ambulance Suppliers

    Operational notes for ambulance-related claims and the type of information used to support transport and service reporting.

13. Timely and Accurate Claims Processing

    Closing emphasis on claim completeness, processing timeliness, and the importance of including required diagnostic information.