Jim,
See attached response from Bob Poiesz, who is one of the co-chairs of the
835 workgroup in X12. Bob's reference to section 2.2.6 is in the 835 4010
implementation guide. Hope this helps.
Doug Renshaw
Highmark
----- Forwarded by Doug Renshaw/OPERATIONS/CORP/Highmark on 04/09/02 03:01
PM -----
Robert D
Poiesz To: Doug
Renshaw/OPERATIONS/CORP/Highmark@HighmarkNotes
cc: Jim
Spare/ISG/CORP/Highmark@HighmarkNotes, Karen R
04/09/02 02:53 Shutt/ISG/CORP/Highmark@HighmarkNotes
PM Subject: Re: How to Pay a Claim that has
been Bundled?(Document link:
Doug Renshaw)
Doug,
Based upon the wording of the question, there are two possible situations.
1 - If the bundled "internal CPT4 code" is a local code internal to their
system only, then they are using valid logic. They can not send out that
local code in the 835 and be compliant.
2 - If the bundled code is a valid (HIPAA compliant) CPT4 code then they
should be following the bundling instructions in section 2.2.6. The
procedure described below is not consistent with those instructions. While
all of the original lines need to be returned on the 835, only one of the
bundled lines would show a payment.
Bob
Doug Renshaw
To: Robert D
Poiesz/ISG/CORP/Highmark@HighmarkNotes
04/09/2002 cc: Karen R
Shutt/ISG/CORP/Highmark@HighmarkNotes, Jim
02:39 PM Spare/ISG/CORP/Highmark@HighmarkNotes
Subject: How to Pay a Claim that has been
Bundled?
Bob,
This doesn't sound right. Shouldn't the payment be on one line, if that's
how they price? Are there some pages in the front of the 835 guide that we
could refer Mr. Morres to?
Doug
----- Forwarded by Doug Renshaw/OPERATIONS/CORP/Highmark on 04/09/02 02:36
PM -----
"Jim Moores"
<Jim.Moores@AntaresSolu To: [EMAIL PROTECTED],
[EMAIL PROTECTED]
tions.com> cc: "George Kaye"
<[EMAIL PROTECTED]>
Subject: How to Pay a Claim that
has been Bundled?
04/09/02 01:40 PM
Hi All,
Question.... We bundle claim lines for a number of reasons, and we pay
them as bundled today. In the future, of course, we will have to create an
835 with all the original lines as we received them.
I need some feedback from all the members but I'm particularly interested
in the provider community....
If we get a 4 line claim and we collapse the lines into 1 line (ie a
Physical Therapy Claim with 4 modes in one visit... for example). We'll
collapse that into a internal CPT4 code to price it as one visit with
moderate levels of treatment. When we pay we must translate that one line
(with it's internal code) back into the four lines on the 835. What we're
proposing to do is pro-rate the payment amount across all non-rejected
lines that were bundled based upon submitted charge (in this case all four
lines would get a portion of the payment).
Question: Would this be HIPAA compliant and would the provider systems
be able to process the 835?
Everything that I've been able to find on this situation suggests that as
long as we return what we received on the 837 and follow the rules in
constructing the 835 regarding payment specific data elements, we should be
compliant.
Any thoughts or comments are welcome....
Jim Moores
Jim Moores - HIPAA Team Leader - Privacy
Antares Management Solutions
23700 Commerce Park Road
Beachwood, Ohio 44122-5832
[EMAIL PROTECTED]
Phone: (216)292-1605
Fax: (216)292-1619
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