Please see the attached from Kathy Simmons. ********************************************************************** 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.
As Jan mentions, crosswalking of a payer's edits to the reason codes can be very complicated. A single reason code may apply to multiple edits. In the past, a payer may have used a different local message for each edit rather than the more generic CAS reason codes. A payer may now need to use one or more remark codes, in addition to a reason code, to explain an adjudication action resulting in denial or reduction of a service. A payer may even need to request a new reason and/or remark code from the code maintainers if their business need cannot be accommodated with existing reason and remark codes. Regarding mapping of the group codes, there cannot be a standard cross-industry mapping of those codes. As Jan mentioned, different group codes may apply to the same reason code, depending upon the condition of use and the coverage policies of individual payers. For instance, legislation prohibits most provider billing of patients for most services that Medicare considers not to be reasonable and necessary for a patient's care, but other payers do not have a similar requirement or policy. Medicare would use a CO group code in that situation, but another payer might appropriately use PI or PR. Even for Medicare, if a provider advises a patient of Medicare's non-coverage policy for a certain service, but the beneficiary elects to receive the service anyway and signs an agreement to that effect, the PR group would be used, rather than CO. Also, the same service might be considered medically unnecessary for one patient based on the patient's diagnosis, condition, age, sex, frequency,or other criteria, but fully appropriate for another patient leading to use of different group and reason codes for the same service with different patients. It is not possible to devise a group and reason code map that would apply equally to every payer and patient. Each payer must construct such a map to reflect their own situation and policies, while adhering to 835 implementation guide requirements and maintainer guidelines for the use of these codes in an 835. >>> [EMAIL PROTECTED] 09/07/01 12:19PM >>> Joseph Xwalking existing payer edits to the group and adjustment reason codes is a very complex task. I am attaching a sample document of work that UHIN has done on this. We pooled edits from many payers and, as a group, xwalked payer edits to the 835 codes. You'll notice that most adjustment codes have more than one group code to go with them. You're going to ask me what the various colors on the spreadsheet mean and I'm going to have to confess that I don't
