Diagnosis Codes – New 5010 Requirement

The Centers for Medicare & Medicaid Services (CMS) has mandated that, effective
January 1, 2012, the standards for electronic health-care transactions must change from 
version 4010/4010A1 to version 5010. MassHealth is actively working toward this 
implementation date (see All Provider Bulletin 210).

Effective January 1, 2012, all MassHealth providers submitting claims via electronic, paper, or 
direct data entry (DDE) methods, must include a valid diagnosis code on their claims. Providers 
must use the ICD-9-CM diagnosis codes or, if applicable, use diagnosis codes from the DSM-IV-
TR (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revision).

This change also impacts MassHealth providers who are not currently required to submit 
diagnosis codes with their claim submissions.

This new requirement does not apply to dental providers submitting claims on the American 
Dental Association (ADA) claim form.
Why are diagnosis codes now required on all claims? 

The implementation of 5010 will help lay the groundwork for the ICD-10 diagnosis and 
procedure codes that must be implemented by October 1, 2013. Diagnosis codes are being 
required as part of this implementation. If your claim does not contain a diagnosis code, it will 
be denied.
5010 allows providers to enter up to a maximum of 12 diagnosis codes. Even though you can 
report up to 12 diagnosis codes, you can only point or link four of those codes to a particular 
service at the line level.
What diagnosis code(s) should I put on the claim? 

You should enter the appropriate diagnosis codes for the service you are providing based on 
the existing ICD-9-CM diagnosis codes.
What is the diagnosis cross reference (Pointer)? 

Since diagnosis codes are required on all claims, another associated field will also be required – 
the diagnosis cross reference. The purpose of this field is to associate the procedure with one of 
four of the diagnosis codes you have listed on the claim.  If your claim does not contain a 
diagnosis cross reference value, it will be denied.
Diagnosis Code Tips for All Providers

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