Bob - I'm not sure if there is simple way to map the "YES/NO" response
check box on the CMS 1500 directly to a segment or element within the 837.
Some background: Field 20 on the paper claim form is used to indicate if
any lab work on the claim was performed by an outside lab or not. The
instructions provided by Medicare on the completion of this field states:
"Item 20. Complete this item when billing for diagnostic tests subject to
purchase price limitations. Enter the purchase price under changes if the
"yes" box is checked. A "yes" check indicates that an entity other than
the entity billing for the service performed the diagnostic test. A "no"
check indicates that "no purchased services are included on the claim".
When "yes" is annotated, item 32 (name and address where services were
provided) must be completed. When billing for multiple purchased
diagnostic tests, each test must be submitted on a separate claim form."
Box 20 is a field that is supposedly to be filled out only for Medicare
claims, but it's my understanding that sometimes it is completed for other
types of plans.
Your analysis indicates that if Box 20 is marked "YES" then the 2310D loop
of the 837 Professional Claim should be completed. As you know, the 2310D
loop is used to indicate a "Service Facility Location" and it applies to
the entire claim unless overridden at the service line level. So, if a
provider marks "YES" in field 20 we would need to know for certain that the
provider intended to indicate that all of the lines of service on the CMS
1500 were performed at an outside lab and that lab name and address is
properly listed in box #33. (I think you will find that sometimes
providers indicate that an outside lab was used but the lines of service on
the claim include both procedures done at the providers office and lab work
done at an outside lab and that sometimes box #33 has the name and address
of the providers office, not the lab)
But if we assume that the provider completed the CMS form by indicating
that "YES" an Outside Lab was used and that box 33 contains the name and
address of the outside lab and that all lines of service on the claim were
lab services performed by that outside lab, then "yes", it appears
possible to use loop 2310D to convey a "Service Facility Location" that is
different from Billing Provider or Pay-To Provider locations.
In your analysis you ask if it's appropriate to assume the following: That
the value present in the NM101 at Loop 2310D, Entity Code Identifier,
corresponds directly to the "X" in box 20 of the CMS 1500. You state that
"IL - Independent Lab" could indicate "Yes - Outside Lab is indicated" and
that the code "TL" could indicate that "No - Outside lab is not indicated".
It is my understanding that this was not the intention for the use of these
codes and that they do not directly correspond or map to Box 20 of the CMS
1500. It appears that there is some direct correlation between the NSF
claim format and the data content present in Loop 2310D, but it's difficult
to make that same linkage from the paper claim form to that loop.
>>THIS ANALYSIS IS SIMPLY MY OPINION. You may want to check with the
authors of the 837P Implementation Guide for further interpretation<<
Catherine Schulten
Sybase, Inc
6550 Rock Spring Drive
Suite 800
Bethesda, MD 20817
W: 301-896-1467
C: 703-338-6955
Bob Ford
<BFord@Unilab. To: Bob Ford <[EMAIL PROTECTED]>,
"'[EMAIL PROTECTED]'"
com> <[EMAIL PROTECTED]>
cc:
05/22/2002 Subject: RE: Outside Lab and charges
03:41 PM
It appears from the lack of any response that I have asked a question not
applicable to this group.
Can any advise as to the correct group to solicit input from.
Thanks
Bob Ford
mailto:[EMAIL PROTECTED]
-----Original Message-----
From: Bob Ford [mailto:[EMAIL PROTECTED]]
Sent: Monday, May 13, 2002 9:57 AM
To: '[EMAIL PROTECTED]'
Subject: Outside Lab and charges
I hope this is the correct place to ask this question.
I have seen a cosswalk from the HCFA1500 to the 837. When referencing box
20 "Outside Lab Yes/No and Charges", it was not clear how these should be
mapped. So, I would like to ask if the following then could be considered
correct:
In Loop ID - 2310D Service Facility Location, outside lab will be
identified by the identifiers on the NM1 segment.
If the NM101 Entity Code is "IL", this will indicate that the "Outside Lab
is Yes". For these transactions, a PS1 segment will be required in loop
2400 to disclose the charges to be reported in box 20 "Charges".
If the NM101 Entity Code is "TL", this will indicate an affiliated "Testing
Laboratory", so, box 20 "Outside Lab is NO". No PS1 segment will not be
required because charges are not required when Outside Lab is NO.
Bob Ford
[EMAIL PROTECTED]
401-822-1962
