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Back  RFI # 1219: 835 Splitting CPT

Formal vs. Informal Help Informal Formal

Submitter

Patrice Kuppe

Description

A payor is splitting the procedure on remits because the patient has met their yearly deductible or out of pocket maximum, causing a different benefit level when in the middle of processing a single unit of service. Examples:

Billed on claim - 99396, quantity 1 for DOS 11/1/10 for $246.00
Came back on remit/835 as:
1 - 99396 Preventive Visit, Est, 40-64 Submitted Charge 237.95 Covered 200.00 Non-covered 37.95
2 - 99396 Preventive Visit, Est, 40-64 Submitted Charge 8.05 Covered 6.77 Non-covered 1.28
total payment $206.77

Billed on claim - 99233, quantity 1 for 11/20/10 for $241.00.
Came back on remit/835 as:
1 - 99233 Subq. Hosp- Day E& Sig Cmpl 35 M Submitted Charge 205.15 Covered 127.88 Non-cov 45.30 Co-in 31.97
2 - 99233 Subq. Hosp- Day E& Sig Cmpl 35 M Submitted Charge 35.85 Covered 35.85
Total payment $163.73

Is this valid under the guide?

Response

The situation described is not unbundling or service line splitting and is not described in the guide. Please refer to section 1.10.2.14.1 line splitting as a result of adjudication instructions.
"Line splitting reported in the 835 may only be a result of a business issue. Line splitting
as a result of an adjudication system limitation (Technical Issue), must be recombined
prior to reporting in the 835" We can see no valid business scenario for the examples described.
Submission 1/3/2011
Status Date 2/11/2011
Status F - Final
Primary References
Document 835
SectionANY
PageANY
Set ID835