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Back  RFI # 2165: Line Splitting Vs Un-bundling

Formal vs. Informal Help Informal Formal

Submitter

Andrew Lee

Description

We have a situation that we are having trouble dealing with from a payer. It looks like they are confusing Line Splitting with Un-Bundling.

We sent a 20610 with a 50 modifier, 1 unit, with a billed amount of $420.00. The payer then returned an 835 with two separate payments, with the following data.

Payment 1
Billed Amount: $420.00
Payment Amount: $111.31
Adjudications: CO-45 $308.69

Payment 2
Billed Amount: $0.00
Payment Amount: $55.66
Adjudications: OA-94 -$55.66

They attempted to split the payments to pay 150% as they normally would pay a bilateral, in two payment. The problem is they didnt decrease the billed amounts on the payments when they split it, which would be a characteristic of line splitting. I would like a determination on what they are doing, Line Splitting or Un-Bundling, and if they are doing it properly. The issue is we now have to writeoff the negative OA-94 so the second payment doesnt go into Insurance Credit in our Practice Management System.

Response

Based upon the information provided, the payer is attempting to unbundle the bilateral procedure into two procedures, one for each side. This is not a case of splitting, as units of service are not conserved, and the submitted unit of service is 1.

While the 835 does not require this action to accurately report payment, it doesn't prohibit it. For instance, the payer could pay using the single service line with the bilateral allowed amount and payment equal to $166.97, with a CAS segment adjustment of CO*45*253.03.

As an unbundling scenario, the information provided in the description is structurally consistent with the guide instructions.

Further details provided when additional information was requested indicate that the payer is not compliant with other instructions within the guide for unbundling. For instance, the full example did not include proper identification of submitted (20610 with modifier 50) and adjudicated (20610 with no modifier) procedure codes.

In addition, with this unbundling, the allowed amount for the procedures should have been the same since each service was for the same procedure code (20610). Therefore, technically, the payment 2 should have reported two adjustments:

OA*94*-111.31

CO*59*55.65

CARC 59 means "Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present."

Recommendation

The workgroup recommends reporting 1 service line.

Using the example provided, the data would be reported as:

Payment 1

Billed Amount: 420.00

Payment Amount: 166.97

Adjustments: CO 45 253.03
Submission 7/27/2016
Status Date 4/25/2017
Status F - Final
Primary References
Document 005010X221
Section1.10.2.6
Secondary References
RFI ID 2642
Document 005010X221
Section1.10.2
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