Per guidelines associated with 837P (Professional) the maximum allowed diagnosis codes are 12 per encounter submission.
If the vendor needs to report more than 12 professional diagnosis codes, subsequent encounter(s) should be submitted.
If there are more than 12 diagnoses, submit a 2nd claim using CPT code 99499 and bill a $0 charge on the additional claim. Include the additional diagnosis codes that went beyond the maximum codes allowed from original claim on this new claim. This will allow up to 24 total diagnoses.
If appropriate, submit remaining diagnoses on a 3rd claim using CPT code 99499 with modifier 25 and bill a $0 on an additional claim. This will allow up to a maximum of 36 total diagnosis codes between the three claims.
Using CPT code 99499 enables providers to submit all documented encounter diagnosis codes.
The following link is to the CMS Medicare Claims Processing Manual: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104C12.pdf
Guidelines for submitting 99499 claims
- All ICD-10 codes must be supported in the documentation of a face-to-face visit
- The 99499 claim should only be used when there is a primary claim with an E&M code
- 99499 claims should only be used when the provider-submitted primary claim contains the maximum of 12 diagnosis codes; if the maximum number of diagnosis codes was not submitted on the primary claim, use the corrected claim process to submit additional diagnoses instead of a 99499 claim
- The member name, billing provider, rendering provider, and date of service must match the primary claim
- No other services should be billed on the claim with CPT code 99499
- 99499 claims are not corrected or replacement claims, so frequency codes 6 or 7 would not be needed
- Multiple units of 99499 are billable on same DOS when used appropriately with modifier 25
- Bill 99499 claims with a zero-dollar ($0.00) charge
