Billing Requirements for Diagnosis Code Limits

ANSI X12 electronic claim transactions have the following limits for diagnosis codes.

  • 837P (professional) limit: 12 diagnosis codes.
  • 837D (dental) limit: 4 diagnosis codes.
  • 837I (institutional): Allows for 24 “other” diagnosis codes in addition to principal diagnosis, admitting diagnosis, patient’s reason for visit, or external cause of injury.

If you have Medicare, Apple Health, or Integrated Managed Care patients that have more than the allowed number of diagnoses on one claim, please submit additional claims to capture all diagnoses for the patient:

  • One with the procedure code(s) for the service(s) rendered with the allotted diagnosis codes.
  • The additional claim(s) with procedure code 99080, billed amount 0.01 (one cent) with the additional diagnoses. Because code 99080 is not a duplicate procedure billed for the member on the same date of service, it will not be denied as a duplicate. Medicare and Medicaid do not cover this code, so CHPW, CMS, and the Washington State Health Care Authority (HCA) will not pay on the one cent. However, the encounter data will be sent to both CMS and the HCA with the additional diagnoses included. Please contact edi.support@chpw.org if you have any questions.