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Back  RFI # 1323: More than 4 modifiers

Formal vs. Informal Help Informal Formal

Submitter

Chip Evelsizer

Description

The 5010 837 and 835 TR3s currently only support a max of 4 modifier codes for each service line. This is consistent with the CMS1500 and UB04 billing instructions. Industry business cases exist requiring more than 4 modifiers per line. A known recommended solution has been defined wherein when more than 4 modifiers are necessary, the 4th modifier will be ‘99’ and all additional modifiers should be placed in the 2400 NTE segment (3 meaningful modifiers in Data Element 1339 with all others in NTE). If used for this purpose, the NTE would always contain at least 2 separate modifier codes. Is this best practice compliant with the 5010 TR3 rules (including the X12 Comments 1 for NTE)? If 5 or more modifier codes are used in adjudication, which codes should be returned in the 835? Is there any plan to accommodate more than 4 modifier codes in future guides?

Submitter Assigned Keywords

modifier

Response

The placing of any information the provider deems necessary to substantiate the medical treatment that is not supported elsewhere within the claim data set, is consistent with the NTE segment of the 5010 837 TR3's. The 837 Work Group has addressed this issue in the next version by adding four additional modifiers. The 837 Work Group will not address a specific work around for 5010, leaving that up to the exchanging entities.

The 5010 835 TR3 does not support NTE segments and therefore cannot return additional data that was applicable to claim processing (for example more than 4 modifiers). The 835 workgroup has addressed this issue in the next version by adding 4 additional modifiers.

Recommendation

For the 835, when more than 4 modifiers were submitted for processing consideration, payers could consider and report in SVC01 (adjudicated data) the modifiers which were most relevant to processing/pricing of the services.
Submission 5/23/2011
Status Date 9/14/2011
Status F - Final
Primary References
Document 005010X222
Section2.4