There’s a new information bubble icon in Benefit Explainer

Benefit Explainer users now see a new information bubble icon when viewing a standalone Primary Diagnosis limitation rule. The change took place on Feb. 8, 2021.

Facility outpatient claims are required to be billed with a HCPCS code. During claims processing, the Primary Diagnosis rule for the HCPCS code is applied to the outpatient facility claim. A provider can submit up to 25 diagnoses on a facility claim.

The information in the new icon indicates the location of the diagnosis on the facility claim that applies to the Primary Diagnosis rule.

When a user hovers over the icon, it will show how the standalone Primary Diagnosis rule is applied to an outpatient facility claim billed with the same HCPCS code. 

The four types of information that could appear in the information bubble are:

• Primary — The diagnosis restriction on the outpatient facility claim will only be based on the primary diagnosis code billed.
• Primary or Secondary — The diagnosis restriction on the outpatient facility claim will be based on the primary diagnosis or the second diagnosis code billed.
• Any — The diagnosis restriction on the outpatient facility claim will be based on any diagnosis code billed.
• Does not apply — A diagnosis restriction will not be applied to the outpatient facility claim.

The screenshot below is a view of what users can expect to see. The screenshot is of HCPCS code J0185 on the Medical/Payment Policy tab under Coverage Limitations, Medical, Primary Diagnosis.

When a user hovers over the icon, the type of diagnosis information will appear.

If you have any questions, contact Provider Inquiry.