Highmark’s Provider Relations and Medical Policy areas are reporting that some confusion exists among providers regarding the wording and usage of certain procedure codes when submitting claims. This issue is causing a larger-than-normal amount of claims to be rejected with rejection codes P5173 or P5039.
Rejection Code P5173
P5173 — In order to process the claim, additional information is required. The claim should be resubmitted with a valid procedure code and an associated diagnosis code.
Providers may misunderstand this rejection code and believe that because the description of the service contains the words “routine” or “screening,” the routine or screening diagnosis matches the procedure code. Although the words “routine” or “preventative” are included in the description of the service, it does not mean the service falls into either of those categories.
Examples are procedure codes 88142 and 88175, which have the word “screening” in the description but are considered to be diagnostic pathology services. These are being billed with a routine diagnosis such as V76.2 – special screening for malignant neoplasms of the cervix, or Z11.511 – encounter for screening for HPV.
Another example is procedure code 93010, which has the word “routine” in the description but is considered to be a diagnostic medical service. This service is being billed with a routine diagnosis such as Z13.6 – encounter for screening for cardiovascular disorders.
In order for claims with these procedure codes or any similar procedure codes to be processed correctly, the diagnosis code must not be considered “routine” or “preventative” when the claim is being submitted.
Rejection Code P5039
P5039 – In order to process the claim, additional information is required. The claim should be resubmitted with a valid modifier and associated number of services rendered.
Providers continue to report procedure codes with 50, LT, and RT modifiers but only report one unit of service. This causes the claim to reject, and the correction is to change the number of units. When including a modifier on your claim, please be sure to list the associated number of services rendered. For clarification, see the Highmark Blue Shield Office Manual 
, Chapter 5, Claims Submission, Unit 2, Claims Submission and Billing Information. Specifically, see “Reporting Bilateral Procedures,” on page 50.
As a reminder, NaviNet should always be your primary source for information. Many routine claims issues can be resolved using NaviNet.
If you don’t have NaviNet, visit navinet.net today to get access to the system. Current NaviNet users who have questions about the system may call 1-888-482-8057 to speak with a NaviNet representative.
