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Back  RFI # 467: 835 Split Service Line

Formal vs. Informal Help Informal Formal

Submitter

Steve Scholze

Description

We submitted a claim with 2 service lines. The first with procedure code 90471 and a charge of $18.00. The second with procedure code 90734 and a charge of $161.00.
The 835 received from the payer contained 3 service lines for the claim. The first was for procedure 90471 and a charge of $18.00. The second service line reported procedure 90734 and a charge of $23.89. The third service line reported procedure 90734 (same as the second service line) and a charge of $137.11. The payer had split a single service line and reported it as 2 (not unbundled) The payment for this claim could not be auto-posted in our system because the info for procedure 97034 was split between 2 lines in the 835. The payer indicated that patient had reached a benefit maximum so the payer split the second service line item for processing under a separate benefit pkg.and thus reported a separate line item on the original claim.
We contend that the split service line s/b reassembled in the 835.

Response

This is not addressed in 004010X091A1. However, it is the intent of the authors of the 835 that service line splitting reported in the 835 may only be a result of a business issue. Line splitting as a result of an adjudication system limitation or technical issue, should be recombined prior to reporting in the 835.

When reporting split service lines in the 835, as a result of a business issue, you must:
1. Retain the original submitted procedure code
2. Sum of split lines' units of service must equal the original submitted units of service with each split line.
3. Allocate the submitted charge proportionately by units of service across the split lines. The sum of the split lines' submitted charges must equal the original submitted line charge.
4. Return the line item control number from the original line on all split lines. If no line item control number was received, use the original line item sequence as the line item control number.

Recommendation

Recommend reporting one LQ segment iteration with LQ01 equal to HE and LQ02 equal to N123 (This is a split service and represents a portion of the units from the originally submitted service.)
Submission 10/18/2006
Status Date 1/3/2007
Status F - Final
Primary References
Document 004010X091A1
Section2
Page31,3
Set ID835