We currently have a vendor that is rejecting professional claims where there is an admit and/or discharge date and the place of service on the claim does not indicate an inpatient POS - for example an outpatient POS of 22 with admit date of 11/14, discharge date of 11/16/15, line svc dates of 11/15 and 11/16/16. We have gone through several RFIs (1486, 1512 and 1840) and while they touch on our issue we feel that there is room for interpretation in them. While they are pretty clear that the date is required when any line on the claim is an IP POS but what we want to know is if there is no line at all on the claim that has an IP POS and the admit date is used, was it the intention of X12 that the claim not be accepted? We have asked CMS if they would reject this type of claim submission and they replied that they take a broad view of the 'if not required, do not send' language and if it does not harm claims processing, they would not reject the claim due to the additional element.
Submitting the admit and/or discharge date for outpatient services is not compliant with the TR3. As stated in RFI 1512, ASC X12 does not govern the receiver's actions when receiving a transaction that is not compliant with the specified TR3. The situational rules for date of admission (2300 DTP with 435 qualifier) specify: “Required on all ambulance claims when the patient was known to be admitted to the hospital. Or Required on all claims involving inpatient medical visits. If not required by the implementation guide do not send." The situational rule for date of discharge (2300 DTP with 096 qualifier) specify: “Required for inpatient claims when the patient was discharged from the facility and the discharge date is known. If not required by the implementation guide, do not send.” A claim that contains only outpatient services does not meet either situational rule. Section 2.2.1.1 states "The receiver will handle non-compliant transactions based on its business process and any applicable regulations." While the receiver may choose to ignore non-compliant data, the receiver retains the option to reject a non-compliant transaction.