Cigna – Unacceptable Primary/Principal Diagnosis: Administrative Denial Policy

For dates of service on or after June 16, 2024, Cigna will administratively deny claims when an unacceptable primary or principal diagnosis code is the only code billed.

Unacceptable Primary/Principal Diagnosis (R38) defined as follows:

Unacceptable Primary Diagnosis: ICD-10-CM instructions indicate the diagnosis reported for Professional or Outpatient facility services is inappropriate as the first listed or primary diagnosis on a claim line.

Unacceptable Principal Diagnosis: ICD-10-CM instructions indicate the diagnosis reported for Inpatient facility claim is inappropriate as the principal diagnosis.

Source: https://providernewsroom.com/cigna-healthcare/clinical-reimbursement-and-administrative-policy-updates/