Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: September 27, 2018

Program Area: Distributed Data Collection (DDC) for RA Including HCRP/EDGE Server

Question: Can issuers submit a default diagnosis code for medical claims (akin to dental/vision)?

Answer: The EDGE Server Business Rules (ESBR) Section 7.4 describes the limited circumstances in which default values are permitted. While the use of default diagnosis codes for dental and vision services is permitted as outlined in ESBR Section 7.7, the use of default diagnosis codes for medical services is NOT permitted. Unless otherwise specified in the ESBR Section 7, issuers cannot use default diagnosis as a general business practice for medical claims.

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