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Back  RFI # 718: Substance Abuse - in/out pat.

Formal vs. Informal Help Informal Formal

Submitter

Bob Resh

Description

For the Substance Abuse Service Type Code (EB03=AI) we have different benefit requirements for inpatient and outpatient services. We can't find any way to identify this difference within the 271 using the EB or HSD segments. Are we correct that inpatient and outpatient substance abuse benefits can't be separately identified in the 271 transaction? If they can be identified, please advise us as to how to identify them, or - should the MSG segment be used?

Submitter Assigned Keywords

Inpatient Outpatient Substance abuse

Response

The conclusion that inpatient and outpatient substance abuse benefits can't be separately identified in the 271 transaction is incorrect; these can be separately identified in the 271. You can use the 2115C/D III segment to identify the Place of Service code associated with any Service Type Code identified in EB03. III02 will contain the Place of Service Code when III01 is ZZ. In this case, for Substance Abuse, there are two very specific Place of Service codes that exist:

55 Residential Substance Abuse Treatment Facility
57 Non-residential Substance Abuse Treatment Facility

Note: Code 57 does not appear in 004010X092 Implementation Guide as that code was added subsequent to the guideā€™s publication. As indicated in the Implementation Guide, the actual list available from the code source identified is to be used.

Recommendation

If these codes do not suit your needs, you may use any of the other Place of Service codes from Code source 237. This is the same code list that is used for Place of Service codes in the 837 Professional Claim transaction in CLM05-1 and SV105.

The MSG segment cannot be used for these purposes as this can be codified (per 004010X092 2110C and 2110D MSG segment note 2).

If these codes do not directly address your need, review all of the available codes in the Place of Service type code list available from CMS. The same codes that would be required on an 837 claim should be identified in the 2115C/D III segment.
Submission 1/5/2009
Status Date 5/19/2009
Status F - Final
Primary References
Document 004010x092A1
Section3
Page218
Set ID271
Table2
Loop2110CD
Segment IDEB