Description:
The purpose of this policy is to establish guidelines for changing diagnosis codes on claims submitted from providers who do not know the appropriate diagnosis code or have access to such due to the nature and scope of their respective medical practices.

Policy Statement:
Diagnosis codes may be changed in the following situations:

• Some claims are filed with a routine diagnosis when the services are performed prior to a scheduled surgical procedure or in conjunction with an office visit or hospital claim.  These claims will deny if the contract does not cover preventive services.  If a member or provider questions the denial and advises that the service was rendered due to one of the situations listed above or if claims history is checked and the associated claim has already been processed, the diagnosis can be changed and reprocessed for appropriate benefits.
• Due to logic deficiencies within AMMS, some deferral codes will instruct processors to change procedure codes or diagnosis codes so that the correct level of benefits will apply (i.e., see deferral DCTAA).
• It is okay to change the diagnosis when claims are flipping inappropriately from Plan 885 (health) to Plan 001 (vision), or vice versa.