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Formal vs. Informal Help Informal Formal

Submitter

joanne hoagland

Description

HIPAA version 5010 837 Institutional - In several places, ABC procedure code qualifiers were added in 5010. At Principal Procedure Code the qualifier is 'CAH'. In other segments (SV202-1, HCP09, SVD03-1) the qualifier is 'WK'. With the segments that utilize the 'WK' qualifier, there is a note in the guide indicating this qualifier can only be used by "parties registered in the the pilot project, and their trading partners". This note does not appear when the 'CAH' qualifier is used. Is it safe to assume that as a payer, we can reject 837 Institutional claims up front when received with these procedure codes (either with qualifier CAH or WK) if we do not participate in the pilot?? Thank you.

Response

Based on CMS FAQ 2458 the pilot project approved in January 2003 by the Secretary of HHS was discontinued on October 16, 2006. Therefore, as of this date, covered entities may not use the codes in HIPAA transactions, including those covered entities who registered for the pilot. Covered entities and non-covered entities may use the codes for non-HIPAA transactions.

The intent of the 837 workgroup was to only allow Advanced Billing Concepts Codes as defined within the note for all applicable ABC code qualifiers. The CAH qualifier which also represents ABC Codes should have included this note. Since the pilot was discontinued after the 5010X223A1 TR3 was published the workgroup will consider whether or not to leave the ABC Code qualifiers (where applicable) in a future version of the Institutional 837 TR3.
Submission 11/4/2009
Status Date 12/18/2009
Status F - Final
Primary References
Document 005010X223
Sectionvarious
Page240
Set ID837 I