June 23, 2025 -- On March 15, 2025, the Centers for Medicare & Medicaid Services (CMS) issued Transmittal 13074 (Change Request 13882) related to Principal Diagnosis Code Reporting Update for Hospice and Manual Updates to Sections 30.3, 40.2, and 50 of Chapter 11 of the Claims Processing Manual: Processing Hospice Claims with an effective date of April 1, 2025.
In this Transmittal, CMS states: The purpose of this Change Request (CR) is to provide an updated list of unacceptable principal diagnosis codes under the hospice benefit. CMS also reminds providers:
- Codes for symptoms, signs, and ill-defined conditions from Chapter 18 are not to be used as principal diagnosis when a related definitive diagnosis has been established (FY 2025 ICD-10-CM Official Guidelines for Coding and Reporting, Section II: Selection of Principal Diagnosis, subsection A)
- When the purpose for the admission/encounter is rehabilitation, sequence first the code for the condition for which the service is being performed (FY 2025 ICD-10-CM Official Guidelines for Coding and Reporting, Section II: Selection of Principal Diagnosis, subsection K)
In addition, the April 2025 I/OCE updates referred to in this Transmittal include a list of diagnoses considered unacceptable as principal diagnoses by CMS for which Medicare Beneficiaries often seek rehabilitative services. Therefore it has come to the attention of Powerback that our customers, business partners, providers and patients could be impacted by these updates. When a code deemed unacceptable for principal diagnosis is used, the claim will be returned to the provider.
For reference, the folowing ICD-10 codes have been added to the list of diagnoses considered unacceptable as principal diagnoses: F01.511, F01.518, F01.52-F01.54, F01.A11, F01.A18, F01.A2-A4, F01.B0, F01.B11, F01.B18, F01.B2-B4, F01.C0, F01.C11, F01.C18, F01.C2-C4, F02.80, F02.811, F01.818, F02.82-82, F02.A0, F02.A11, F02.A18, F02.A2-A4, F02.B0, F02.B11, F02.B18, F02.B2-B4, F02.C0, F02.C11, F02.C18, F02.C2-C4, F03.90, F03.911, F03.918, F03.92-94, F03.A0, F03.A11, F03.A18, F03.A2-A4, F03.B0, F03.B11, F03.B18, F03.B2-B4, F03.C0, F03.C11, F03.C18, F03.C2-C4, F09. You can find the complete list here.
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