What happens to claims that have invalid or missing diagnosis codes?

In the context of claims processing, when diagnosis codes are invalid or missing, it is crucial to adhere to proper coding guidelines for the claim to be accepted. Claims with such issues typically do not proceed through the automated approval process. Rather than being automatically approved or denied outright, these claims face a specific response: they are often returned to the provider for correction. This ensures that healthcare providers are aware of the errors and can revise the claim with the appropriate and valid diagnosis codes before resubmission.

Returning the claim allows the provider the opportunity to rectify the issue and resubmit the claim correctly, facilitating the proper handling of the claim process according to Medicare regulations. In this way, the system encourages accurate coding, which is essential for ensuring that healthcare services are billed correctly and reimbursement is processed without delays.