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Back  RFI # 2283: Service Lines 837 vs 835

Formal vs. Informal Help Informal Formal

Submitter

Jason Link

Description

Hello everyone,

I have been reviewing Front Matter section 1.10.2.6 Procedure Code Bundling and Unbundling of the 5010 835 Implementation Guide, and am seeking guidance and feedback about acceptable/compliant practices related to the number of claim lines returned on the 835.

In the event that additional service lines are added to claim during the adjudication process (such as unbundling or other reasons), will the 835 be compliant if it returns more SVC segment for a claim than what was submitted on the 837 claim?

Response

There are valid business reasons for reporting more service lines in the 835 remittance than were reported in the 837 claim. It is compliant with the 835 to report additional service lines when splitting lines and unbundling lines. Requirements for splitting or unbundling lines are outlined in Sections 1.10.2.14.1 Service Line Splitting and 1.10.2.6 Procedure Code Bundling and Unbundling.

Section 1.10.2.14.1 Service Line Splitting reads in part:

“Characteristics of Line Splitting vs Unbundling:

Line Splitting:

A submitted service line would be split into multiple lines.

Adjudicated Procedure code may or may not be the same as the submitted procedure code across split service lines in the SVC Segment.

The sum of the split line units must equal the total submitted units from the original service line.

Unbundling:

A submitted service line is reported as more than one SVC segment.

The adjudicated procedure code in the SVC segment will always be different than the submitted procedure code. Note: an exception to this is partial unbundling.

The sum of the unbundled units of service is greater than the total submitted units from the original service line.”

Section 1.10.2.6 Procedure Code Bundling and Unbundling reads in part:

“When unbundling, report the original service as the first of the new services with the original submitted charge in SVC02. Use subsequent SVC loops for the other new services. For these other services, report the submitted charge as zero dollars ($0.00). As in bundling, CAS is used to increase the submitted charge from $0.00 to the allowed amount for each procedure. Report the original procedure code in all of the SVC loops in SVC06. Balancing must be maintained for all service lines.”
Submission 4/12/2018
Status Date 5/18/2018
Status F - Final
Primary References
Document 005010X221
Section1.10.2.6