Section title: Requests for Interpretation
RFI #
2424
835 Modifiers
Description

SVC01-3 modifier is required to report the adjudicated modifier when the there is a difference than the original submitted modifier returned in the SVC06-3.

My question is if an internal modifier is being used to adjudicate the claim that is not part of the HCPC, or CPT modifier code set does it need to be returned in the SVC01-3? Example internal modifier XZ used to identify a procedure that is non-medically necessary.

The TR3 does note under Procedure Modifier, “This identifies special circumstances related to the performance of the service, as defined by trading partners”. Based on this verbiage I would say we should be returning internal modifiers used in the adjudication of the claim. Is this a correct interpretation?

Response

The 835 2110 SVC01-1 data element note states:  “The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7.”  Each qualifier in SVC01-1 has a code source associated with it.  Reporting a non-standard modifier or code that is not part of the associated code source, is not allowed.

DOCUMENT ID
005010X221A1