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Back  RFI # 2071: SVC inpatient DRG add on

Formal vs. Informal Help Informal Formal

Submitter

Barber Meg

Description

When an inpatient claim is reimbursed at the Claim level: example DRG. Per the guide if the payment does not equal the charge the Claim CAS 2100 etc.. is to be used and do not report any Line SVC information. When a claim is reimbursed at DRG plus 'add pay' (DRG plus Blood cost or DME) Some contracts pay the DRG rate and if there is a DME or blood billed that specific line will pay adidtional amounts and we need to show that in the ERA so the provider knows we paid it. Is the Expectation that All lines on the inpatient claim are to be reported (SVC) .. Example Line 1 $5000.00 rev code 121 (room charge) ; line 2 $200.00 rev code 300 (labs/ancillaries); Line 3 $600.00 rev code 636. DRG is $3000.00 payment, Blood (rev 636) payment is $500.00. How would the SVC's look?
Line 1 show payment of 3000.00 with a CO 45 for 2000.00
Line 2 CO 97 for 200.00
Line 3 show payment of 500.00? with CO 45 for 100.00

Submitter Assigned Keywords

SVC DRG plus single Line payment

Response

This situation is not explicitly defined in the 005010X221A1. Section 1.10.2.4.1 - Institutional-Specific Use indicates it is not always appropriate to report service line data for Institutional Inpatient claims, but recognizes certain situations might require it. Section 1.10.2.1.1 - Service Line balancing indicates 'If any service detail is reported in the claim payment, all services for the claim payment must be reported.' Section 1.10.2.6 - Procedure Code Bundling and Unbundling describes the reporting requirements when services are combined (bundled) for the purpose of processing and payment.

Recommendation

Based on the sections above, 2 options exist for reporting this scenario in the 835.

Option 1 - Split the claim into DRG specific services and the other 'add pay' services. Report the DRG claim at Claim level as recommended by Section 1.10.2.4.1. Process and report the other services at service level. Use ALERT RARC 'MA15' on both claims to indicate the claim was split for processing.

Option 2 - Report all service lines (Section 1.10.2.1.1) thereby allowing the 'add pay' lines (DME, Blood) to be reported/processed per service. However all of lines related to the DRG payment must be considered 'bundled services' and reported according to Section 1.10.2.6.
Submission 6/30/2015
Status Date 8/26/2015
Status F - Final
Primary References
Document 005010X221
Section1.10.2.4
Page23
Set ID835
Loop2110
Segment IDSVC
Element Position01
Industry NameService Line