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Back  RFI # 2009: Bundling svcs from > 1 claim

Formal vs. Informal Help Informal Formal

Submitter

Donald Graves

Description

Section 1.10.2.6 "Procedure Code Bundling and Unbundling" describes how lines of a claim are to be reported when bundling occurs. The section restricts itself to a discussion of service lines that are all associated to a single claim. I have discovered that our claims department routinely bundles service lines from several claims into a single bundled line on one claim ("...this is not uncommon with lab."). Since section 1.10.2.6 does not mention bundling that spans claims, is this business practice in compliance with section 1.10.2.6?

Submitter Assigned Keywords

Bundling

Response

The submitter clarified that their current process reports back multiple claims (as submitted) with one line as primary in one claim and all other lines denied in their respective claims. That process does not report adjudicated procedure codes on the denied lines that are different than the submitted procedure codes. The denied lines also report zero submitted charge.

While section 1.10.2.6 describes bundling within a single claim and there is no explicit section describing bundling of services from different claims, there is nothing prohibiting that practice. Section 1.10.2.14 does identify the principles necessary for this process. In summary, similar reporting as in bundling would be used on each of the claims involved:

All related service lines would indicate the adjudicated and submitted procedure codes using SVC01 and SVC06

Unpaid procedures would use Claim Adjustment Reason Code 97 (which currently reads "The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.") to adjust those service lines to a $0 payment

When determining other specifics for reporting, implement the message from section 1.10.2.14 - to "...give the provider a message that will not result in calls to customer service." While unspoken in section 1.10.2.14, identification of any remaining patient responsibility would be critical to avoiding calls.

Reporting the denied lines that were bundled across claims without identifying the adjudicated procedure as the paying procedure in SVC01 and the submitted procedure in SVC06 is not consistent with the guide instructions. The denied service lines need to report the submitted charge from the claim and use CARC 97 to adjust the payment to zero in order to be consistent with the guide.
Submission 2/12/2015
Status Date 3/25/2015
Status F - Final
Primary References
Document 005010X221
Section1.10.2.6
Page25
Set ID835