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Back  RFI # 494: HCPCS in 837I outpatient claim

Formal vs. Informal Help Informal Formal

Submitter

Dyan Anderson

Description

A state Medicaid program is was still requiring ICD-9 procedure codes to be reported in the HI*BR/HI*BQ for outpatient claims which is not allowed. They are now requiring HCPCS codes to be reported at the claim level HI*BP/HI*BO segment in addition to the HCPCS procedure code reporting at the applicable service line level. We do not see any documented requirement supporting this and do not understand why we'd report claim level HCPCS codes when we are already reporting them at the specific revenue line for which they belong. The X12 notes do not support this nor do the UB92 nor final UB04 specifications. Can the plan require HCPCS procedure codes in the HI*BP/HI*BO segment for outpatient claims?

Submitter Assigned Keywords

outpatient procedure codes HI*BP ICD9

Response

The Principal Procedure HI Segment and the Other Procedure HI Segment are to be used only when:
1.Required on Home IV therapy claims or encounters when surgery was performed during the inpatient stay from which the course of therapy was initiated.
OR
2. Required on inpatient claims or encounters when a procedure was performed.
Per the Implementation Guide Notes, it should not be used for Outpatient Claims.
Submission 12/4/2006
Status Date 2/15/2007
Status F - Final
Primary References
Document 004010X096A1
Section837I
Page242
Set IDHI
Loop2300
Segment Position231
Segment IDHI
Element Position01
Component Position2
Industry NamePRINCIPAL PROCEDURE CODE