New claim edit: Invalid diagnosis pointers

Stedi now rejects 837P professional and 837D dental claims with invalid diagnosis pointers.

How the edit works

In a claim, a diagnosis code describes what’s wrong with the patient, such as tooth decay or lower back pain. A claim can include multiple diagnosis codes, listed and indexed in order of importance. The primary diagnosis code is in position 1, the next is in position 2, and so on.

A service line is a single row on a claim that bills for one specific service, procedure, or supply – such as an office visit or a dental filling.

Each service line can include a diagnosis code pointer. This pointer tells the payer why the service was provided by linking it to a specific diagnosis code. For example, this office visit (service) was provided because of lower back pain (diagnosis). Payers use this information to determine the medical necessity or clinical rationale for the service.

The diagnosis code pointer refers to the index position of a diagnosis code on the claim. For example:

• If a service line uses diagnosis pointer 2, the claim must include a diagnosis code in position 2.

• If a service line uses diagnosis pointer 3, the claim must include a diagnosis code in position 3.

Payers may reject claims that include a diagnosis pointer that refers to a diagnosis code position that isn’t present on the claim. These rejections can delay payment for the provider.

This edit – the industry term for an automated validation rule – catches the issue before the claim reaches the payer.

Where to find diagnosis codes and pointers

• JSON API

  • Professional claims JSON endpoint: 

    • Diagnosis codes: healthCareCodeInformation

    • Diagnosis pointers: serviceLines[].professionalService.compositeDiagnosisCodePointers

  • Dental claims JSON endpoint:

    • Diagnosis codes: healthCareCodeInformation

    • Diagnosis pointers: serviceLines[].dentalService.compositeDiagnosisCodePointers
      
      

• Raw X12

  • Professional claims:

    • Diagnosis codes: HI (Health Care Diagnosis Code) in Loop 2300 (Claim Information)

    • Diagnosis pointers: SV1-07 (Composite Diagnosis Code Pointer) in Loop 2400 (Service Line)

  • Dental claims:

    • Diagnosis codes: HI (Health Care Diagnosis Code) in Loop 2300 (Claim Information)

    • Diagnosis pointers: SV3-11 (Composite Diagnosis Code Pointer) in Loop 2400 (Service Line)
      
      

• Stedi portal

  • Professional claims using the CMS-1500 form:

    • Diagnosis codes: Box 21 – Diagnosis or nature of illness or injury

    • Diagnosis pointers: Box 24e – Diagnosis codes

Rejection errors

If you submit a claim that fails the edit using Stedi’s claim submission APIs, you’ll get back an error message in real time. If you’re using a JSON API endpoint, the response includes error details in the errors array:

{
  "errors": [
    {
      "code": "33",
      "description": The Diagnosis Pointer(s) of 2, 3, 4 on line 0 is/are invalid. The diagnosis pointer must point to an existing diagnosis code on the claim. Correct and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

If you submit a claim that fails the edit using SFTP, Stedi will reject the claim with a 277CA claim acknowledgment. The acknowledgment will include a related claim status category code, claim status code, and error message:

STC*A7:N477*[DATE]*U*[AMOUNT]********The Diagnosis Pointer(s) of 2, 3, 4 on line 0