The 835 X12 states that the SVC in the 2110 loop is situational.
Must an 835 for an outpatient facility claim include service-level adjudication details if the adjudication system paid at a case rate and did not consider the individual service line?
How would the 835 look in the following outpatient facility scenario:
Claim is submitted as outpatient facility with one service totaling 2,389.00.
Revenue Code 610 is submitted with procedure code 73718, 1 UOS
Provider liability is $757.00
Case rate payment is $1632.00
Would the 835 be compliant if the case rate payment is return at the claim level and not the service line level? (See example below)
CLP*7722337*1*2389*1632**15*119932404007801*13*1~
CAS*CO*204*757~
NM1*QC*1*Doe*Sally*J***MI*SJD11111~
NM1*74*1*Right*Samuel~
NM1*82*1******XX*1346474509~
DTM*232*20121106~
DTM*050*20121114~
AMT*AU*1632~
The 2110 loop/SVC segment situational rule states "Required for all services in a professional, dental or outpatient claim priced at the service level or whenever payment for any service line of the claim is different than the original submitted charges due to service specific adjustments.... If not required by this implementation guide, do not send."
Section 1.10.2.1.1 states "Although the service payment information is optional, it is REQUIRED for all professional claims or anytime payment adjustments are related to specific line items from the original submitted claim."
Since the stated scenario seems to not include service specific adjustments, reporting at the claim level only is appropriate for this outpatient institutional claim - assuming that service specific adjustments do not apply.
However, the reference CARC code (204 - This service/equipment/drug is not covered under the patient’s current benefit plan) is inappropriate for the stated business, since a payment is being made. CARC 45 should be used as a reduction from the submitted charge to the case rate. If CARC 204 is appropraite,and another specific service that was not mentioned is not covered, then this is service specific, and then the service level MUST be reported.
In addition, the Coverage Amount (AMT*AU) is only for a portion of the submitted charge, indicating that at least one of the services is not covered (as AU is defined in the guide). Since there is only one service, this makes no sense. AU is not allowed amount, it is coverage amount.