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Back  RFI # 2028: SVC06 and Additional Modifiers

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Submitter

Christopher Gracon

Description

Our question has to do with the SVC06 and additional modifiers. We have 4 or more modifiers submitted on the original claim. When we adjudicate, we add a modifier. Since only 4 modifiers can be sent in the SVC01 and SVC06, do we have to populate the SVC06 since the first four modifiers are the same since this would be against the situational rule, though there is a difference in the non-displayed modifiers? Or should we send three of the originally sent modifiers and the one we added so that the provider knows that we added a modifier (so that it is different from the submitted), and then the modifiers in the SVC01 and SVC06 do not match so the SVC06 can be sent?

Submitter Assigned Keywords

835 SVC06 Modifiers

Response

The situational rule for the SVC06 states “Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send If the SVC01-03 through SVC01-06 only contains modifiers that were submitted, in either the SV101/SV201/SV301 or the NTE, then the SVC06 wouldn't be required and shouldn't be sent. If a payer added modifier is being sent back in the SVC01, though, then the SVC06 would be required to be sent.

In a future guide, the number of modifiers will be increased to 8 in both the 837 and 835.

Recommendation

When more than 4 modifiers were used for adjudication, payers should consider and report in the SVC01 (adjudicated data) the modifiers which were most relevant to process/pricing of the services. Payer added modifiers that don't impact adjudication but only are used for processing in the payer system wouldn't be returned.
Submission 3/17/2015
Status Date 8/27/2015
Status F - Final
Primary References
Document 005010X221
Section2.4
Page190
Table2
Loop2110
Segment Position0700
Segment IDSVC
Element Position06
Industry NameSubmitted Procedure Code Infomation