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Back  RFI # 366: proc codes inbound missing/inv

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Submitter

Jodi Fekete

Description

On hard copy claims inbound, sometimes there is a missing/invalid proc code. When the claim gets to the adjudication system, it correctly rejects the claim. Yet on the outbound 835, the 835 is failing compliance since the code is either invalid or incorrect. Can we skip checking the compliance on these types of 835s?

Response

The preferred recommendation would be to return paper claims when there is incomplete or invalid claims data.

Recognizing that all payers may not be able to accommodate this practice, it is the opinion of the 835 work group that the payer provide a valid unlisted code, with the appropriate qualifier in SVC01 and the originally submitted code returned in SVC06. Payers will need to select a valid default code for the SVC01. This requires that all editors relax edits on SVC06.

Office of e-Health Standards and Services (CMS/OESS) supports this opinion.

Recommendation

We recommend that the following default codes would be used in SVC01:

Medical 99199 (HC)
Dental D9999 (AD)
Hosp 0949 (NU)
Submission 11/29/2005
Status Date 5/1/2006
Status F - Final
Primary References
Document 004010x091a1
SectionSVC
Page54
Set IDsvc01