1. Does anyone have the Claim Adjustment Reason Codes grouped together under
the 5 group codes of 'CO' (Contractual Obligations), 'PR(Patient's
Responsibility)' 'PI (Payer Initiated Reductions)', 'CR'(Corrections &
Reversals) and 'OA' (Other Adjustments)?
2. How are the TS3 and TS2 data elements in 835 populated?
Joseph Ponnoly, CISSP
H2HSolutions Inc
28815, W 8 Mile Rd, Ste 103?
Livonia, MI, 48152
248-477-4553
[EMAIL PROTECTED]
----- Original Message -----
From: "Winston, Mike K." <[EMAIL PROTECTED]>
To: <[EMAIL PROTECTED]>; <'[EMAIL PROTECTED]'>
Sent: Thursday, September 06, 2001 2:51 PM
Subject: RE: Bundling units
> Thanks Jan and Bob, this is what I was thinking. Hope the additional
> clarification around bundling and unbundling helps clarify these types of
> issues. It sure does get complicated.
>
> Mike Winston
> Trigon ISD
> Ext 44521
> [EMAIL PROTECTED]
>
> This message, including files attached to it, may contain confidential
> information that is intended only for the use of the ADDRESSEE(S) named
> above. If you are not the intended recipient, you are hereby notified
that
> any dissemination or copying of the information is strictly prohibited.
If
> you have received this message in error, please notify the sender
> immediately and delete the message from your system. Thank you.
>
>
>
>
>
>
> > -----Original Message-----
> > From: Jan Root [SMTP:[EMAIL PROTECTED]]
> > Sent: Thursday, September 06, 2001 12:48 PM
> > To: [EMAIL PROTECTED]
> > Cc: '[EMAIL PROTECTED]'; Bob Poiesz
> > Subject: Re: Bundling units
> >
> > Mike and All
> > Last week I wrote a reply to you regarding your question about the three
> > service lines and I got it wrong. I've been working with Bob Poiesz,
the
> > Co-chair of the 835 WG and now have it correct. Below is the correct
way
> > to handle this question.
> >
> > The situation described of having three service lines, proc code A, B, &
C
> > with 3 units each that were then partially bundled into a fourth proc
code
> > is more complex than initially meets the eye. The example is actually a
> > combination of two separate business situations. First, two of the units
> > of service of each procedure are paid as submitted (no change of codes).
> > Second, one set of the services is bundled into a fourth procedure code,
> > paying half as much. To accomplish this in the 835, we need to separate
> > the two business situations. You could consider this as splitting the
> > service, instead of the claim.
> >
> > Here's the 837:
> >
> > service line 1 - proc code A - 3 units - charge $300
> > service line 2 - proc code B - 3 units - charge $300
> > service line 3 - proc code C - 3 units - charge $300
> >
> > Goal: pay the three lines but pull one unit from each and bundle them to
> > pay under a different proc code.
> >
> > Here's the 835:
> > Billed code Billed units paid units paid code Charge Pay
> > Adjustment
> > A 2 2 A $200
> > $200
> > B 2 2 B $200
> > $200
> > C 2 2 C $200
> > $200
> > A 1 1 D
$100
> > $150
> > CAS*OA*94*-200~
> > CAS*CO*45*150~
> > B 1 0 D $100
> > $ 0
> > CAS*CO*97*100~
> > C 1 0 D $100
> > $ 0
> > CAS*CO*97*100~
> >
> > What was done: each original service line was split into two lines part
of
> > which was paid 'as billed', and part of which was bundled into proc code
> > D.
> >
> > You original estimation of this was bundling was correct. Bob, with the
> > 835 WG, is working on improving the definitions of bundling and
unbundling
> > in the 835. The current definitions don't adequately distinquish them
in
> > a situation like yours.
> >
> > My apologies for getting it wrong the first time!
> >
> > j
> >
> >
> >
> >
> > Jan Root wrote:
> >
> > Mike
> > First, I think what you're talking about is termed 'unbundling'.
> > Bundling is the
> > term used when for example (in the past) the provider submitted
> > three service
> > lines and the payer bundled them up into one or two service lines.
> > While payers
> > may still 'bundle' in the sense that they can roll up lines, the 835
> > requires
> > that they return the same number of lines that were submitted, at
> > least as a
> > minimum. Please see pages 25-27 of the 835 for an excellent
> > discussion of
> > bundling, unbundling and partial unbundling.
> >
> > Unbundling is when the payer wants to create more lines that were
> > billed which it
> > sounds like what you want to do. As far as the units go I think
> > this is what
> > you'd show in the 835:
> >
> > Billed Paid CAS unit adjustment **
> > 81002 3 2 1
> > 81005 3 2 1
> > 81015 3 2 1
> > 81000 0 1 -1
> >
> > So, in this case, you would add a line to the 835 (the 81000) and
> > adjust the
> > units accordingly so that billed = paid.
> >
> > **To quote from the imp guide: "A positive value decreases the paid
> > units of
> > service, and a negative number increases the paid units." The units
> > adjustment
> > goes in CAS04, 07, etc.
> >
> > "Winston, Mike K." wrote:
> >
> > > Can anyone give an example of how you would show on the 835 that
> > some units
> > > from submitted lines were used to create a new line?
> > > Example:3 lines billed, procedures 81002,81005 and 81015 each was
> > billed
> > > with 3 units for the same date of service we currently would take
> > 1 unit
> > > from each line and create a line with procedure 81000. The 835
> > will have 4
> > > lines going out 81002,81005,81015 each with 2 units and 81000 with
> > 1 unit.
> > > Would it be ok to send out a forth line when only three was
> > submitted if we
> > > could not show the forth line as resulting from bundling?
> > >
> > > Thanks
> > >
> > > Mike Winston
> > > Trigon ISD
> > > Ext 44521
> > > [EMAIL PROTECTED]
> > >
> > > This message, including files attached to it, may contain
> > confidential
> > > information that is intended only for the use of the ADDRESSEE(S)
> > named
> > > above. If you are not the intended recipient, you are hereby
> > notified that
> > > any dissemination or copying of the information is strictly
> > prohibited. If
> > > you have received this message in error, please notify the sender
> > > immediately and delete the message from your system. Thank you.
> > >
> > >
> > **********************************************************************
> > > To be removed from this list, send a message to:
> > [EMAIL PROTECTED]
> > > Please note that it may take up to 72 hours to process your
> > request.
> > << File: Card for Jan Root >>
>
> **********************************************************************
> To be removed from this list, send a message to: [EMAIL PROTECTED]
> Please note that it may take up to 72 hours to process your request.
>
**********************************************************************
To be removed from this list, send a message to: [EMAIL PROTECTED]
Please note that it may take up to 72 hours to process your request.
