This is a request for clarity of dental modifiers on the 835. We reviewed RFI 978, which is specific to the 837.
An 837D claim is submitted and adjudicated with one dental procedure code and a modifier on it, even though there are no modifiers in Code Source 135 currently. The claim is processed without using the modifier for adjudication – just the dental procedure code is used for adjudication. Both the procedure code and modifier are stored in the system for that claim.
How should this claim be reported in the 835? Only SVC01 is used, since there is only one submitted and adjudicated procedure code. SVC06 would not be required.
Does just the dental procedure code get sent in SVC01-2, with code AD in SVC01-1?
Does the dental procedure code get sent in SVC01-2, with code AD in SVC01-1, and the modifier from the 837D get sent in SVC01-3, even though it is not valid nor used for adjudication?
When the submitted modifier is not used in adjudication, then an SVC06 is required. This is addressed in RFI 1000. All of SVC06 is tied to SVC01, not just one component. Therefore changes to a modifier represents changes to the procedure code as part of the composite as a whole.
Also, to quote RFI 1784 “The guide requires sending any modifiers used in adjudication in SVC01. If reported modifiers weren’t used during adjudication, then they would not be reported in SVC01, but would then be reported in SVC06 since that is required to report the submitted procedure when different than the adjudicated procedure. Since this is a composite, the procedure includes the modifier.”
So in this case, the procedure code would go in the SVC01-2, there would be no SVC01-3, procedure code would also go in SVC06-2 and the modifier would go in the SVC06-3.