A vendor’s system is not always reporting the submitted procedure code from the original claim in SVC06 when a CAS segment with a CO*97 adjustment against that line is reported and a CAS OA*94 with a negative dollar to the rolled-up service line is reported. When questioned about this inconsistency, the vendor indicated they view these lines as not meeting the SVC06 situational rule requirement. In these situations, they state adjudication does occur using the original submitted procedure code via duplicate checking, medical utilization edits, and clinical edits. They do agree that rollup occurs to another line to perform pricing and payment routines; however, based on performing the other functions using the original submitted procedure code prior to the pricing roll up, they interpret that the original procedure code is the adjudicated service thereby not meeting the SVC06 requirement. Is their interpretation regarding not meeting the SVC06 situational rule correct? Thank you.
In the SVC06 situational rule it explicitly states “Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim.” If the submitted procedure code is not included in the SVC01 then it must be included in the SVC06.
According to section 18.104.22.168 Procedure Code Bundling and Unbundling, paragraph 4, “When bundling, report all of the originally submitted procedures in the remittance advice. Report all procedures as paying on the changed (bundled) procedure code, and reference the original submitted code in SVC06. The bundled service line must be adjusted up by an amount equal to the sum of the other line charges.This is reported as a CAS segment with a group code OA (Other Adjustments) and a reason code of 94 (Processed in Excess of Charges) with a negative dollar amount. From that point, apply all normal CAS adjustments to derive the reimbursement amount. Report the other procedure or procedures as originally submitted, with an adjudicated code of the bundled procedure
code and a Claim Adjustment Reason Code of 97 (payment is included in the allowance for the basic service) and an adjustment amount equal to the submitted charge. The Adjustment Group is either CO (Contractual Obligation) or PI (Payer Initiated) depending on the provider/payer relationship.”
Based on this information from section 22.214.171.124, the example reported is not correct, and must include the submitted procedure code in SVC06.