For dates of service beginning April 4, 2019, when a claim is submitted for a StrideSM (HMO) Medicare Advantage member that includes a Z code with a Primary Diagnosis Only (PDO) requirement, the Z code must be reported as the principal diagnosis for an institutional claim or primary/first-listed diagnosis for a professional claim.
If a claim is submitted with a Z code with a PDO requirement listed in any position other than the first position, the claim will deny and will need to be resubmitted in order for the submitter to be reimbursed. Codes for any subsequent diagnoses resulting from the primary encounter should be reported in the additional diagnosis fields.
Harvard Pilgrim is implementing this coding update to promote the most accurate possible disease classification and reporting, improve claims payment accuracy, and ensure the correct application of member cost share.
For any questions you may have, please contact Harvard Pilgrim’s Medicare Advantage Provider Service Center at 888-609-0692.