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Back  RFI # 213: Group Code/Reason Code repeat

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Submitter

Strickland Curtis

Description

A third party testing organization is issuing an error for an 835 transaction with an explanation: "835 CAS - Group Code/Reason Code combination repeating". They use section 2.2.4 of the IG, page 24, last paragraph as justification for this error. The sentence in the IG says, "...each CAS can report up to six different adjustments....".

We are creating a new CAS segment for each adjustment amount found in the input data. Because of this, we create two segments with Adj. Group/Reason code of CR/23.

This error, only, occurs for a "Reversal" claim. On the "Reversal", it is specified that all Adj.Group Codes must be = "CR". In the original transaction, the Group Codes would have been different (e.g., "PI", "OA"). If I were the provider, I would want to see the reversal as a reflection of the original.

Submitter Assigned Keywords

Group Code/Reason Code combination repeating

Response

It is accurate to refer to 2.2.4 section of the implementation guide. It must be read and interpreted as a whole and not just a part of the section.
The justification for the rule comes from this full sentence.
At either position — the claim level or the service level — each CAS can report
up to six different adjustments related to a particular Claim Adjustment Group.

We can't think of a business scenario where the same code would be used with two different group codes as a valid business situation. You are interpreting the reversal section accurately and creating a CR adjustment for previous adjustments.

Recommendation

Work out with the third party that they not consider this a hard edit if you can provide a valid business reason for the use of an adjustment code with two different group codes.
Submission 3/7/2005
Status Date 9/1/2005
Status F - Final
Primary References
Document 004010X091
Section2.2.4
Page24
Set ID835
Table2
Loop2110
Segment Position080
Segment IDCAS