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Back  RFI # 1784: 835-Reporting Dental Modifiers

Formal vs. Informal Help Informal Formal

Submitter

Ward Lori

Description

This is a request for clarity of dental modifiers on the 835. After reviewing RFI 978 which is specific to the 837. The RFI specifically states there are no approved "dental modifiers" but can be submitted if it improves or clarifies reporting. If the modifiers are stored as informational but not used to adjudicate a claim, are those required to be reported on the 835?

I have read two comments in the IG's, please confirm the interpretation.

1. Modifiers originally submitted on the 837 must be returned on the 835. True or False?
2. This is the adjudicated medical procedure information found on page 187 of the 835 IG. Is this true when only used for adjudication?

Response

The note on SVC01 states that it reports the adjudicated medical procedure information. The note on SVC06 states that it is the submitted procedure code information. The SVC06 composite Situational Rule reads "Required when the adjudicated procedure provided in SVC01 is different from the submitted procedure code from the original claim." This applies to all information within the composite. If the modifiers were submitted on the claim, but were not used for adjudication, then they are not reported in SVC01, but are reported in SVC06.

1 – True. The guide requires sending any modifiers used in adjudication in SVC01. If reported modifiers weren’t used during adjudication, then they would not be reported in SVC01, but would then be reported in SVC06 since that is required to report the submitted procedure when different than the adjudicated procedure. Since this is a composite, the procedure includes the modifier.

2 – Page 187 is referencing SVC01. This element reports the procedure related information (procedure code plus modifiers) that was used in adjudication. It is true that if the submitted modifiers weren’t used in adjudication, then they are not reported in SVC01.
Submission 4/30/2013
Status Date 5/30/2013
Status F - Final
Primary References
Document 005010X221
Section835
Page187
Set ID835
Table2
Loop2110
Segment IDSVC
Element Position01
Component Position3
Industry NameProcedure Modifier
External Code List135