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Back  RFI # 1230: ICD Proc code 835 impact

Formal vs. Informal Help Informal Formal

Submitter

Chip Evelsizer

Description

HIR 1104 final response stated that ICD-9-CM Procedure codes are "never the basis for the payment" and thus were removed from the 5010 835. In New York, under PIP REG68, the ICD-9-CM codes are used to determine fee schedule pricing for ASC services. There may be different pricing outcomes based on the ICD-9-CM included with the bill. (e.g. NY PAS value, NY Inpatient DRG assignment, FL/PA DRG assignment). Since these values did impact adjudication, is it necessary to return them in the remittance?

Submitter Assigned Keywords

ICD-9-CM Procedure

Response

Even though the ICD-9-CM reported on the claim may have been involved in the adjudication process, there is no way to return that in the 835. The instances referenced represent claim level payment methodologies where the service loop is not present (which is where the ICD-9-CM procedure might have been reported in version 4010). The DRG would be reported at the claim level (when applicable). There is not now and never has been a capability in the 835 guides to return any procedure information at the claim level.
Submission 1/20/2011
Status Date 3/11/2011
Status F - Final
Primary References
Document 005010X221
Section2.4
Page187
Set ID835
Table2
Loop2210
Segment PositionSVC