Section title: Requests for Interpretation
CPT on TOB 11X for Revenue code 0450CPT on TOB 11X for Revenue code 0450 (837I)

When sending an 837i inpatient bill for a patient admitted though the emergency room we have different payers that have conflicting requirements and both claiming they are following the x12 standard.  We include the revenue code 0450 and the charge for the emergency room on the inpatient bill and most payers want to see the CPT on the bill as well.  Recently a payer started denying all our inpatient claims when a CPT appeared on the revenue code 0450 service line.  Which payer is correct?


Health Care Claim Transaction Set (837) Institutional

TOB 11X (Inpatient)

Revenue code 0450

ED E&M CPT appears on our inpatient bills for patients admitted through our emergency room

RFI Response

The situational rule for the  SV202 data element states when a HCPCS or HIPPS code can be submitted.  “Required for outpatient claims when an appropriate procedure code exists for this service line item.  OR  Required for inpatient claims when an appropriate HCPC (drugs and/or biologics only) or HIPPS code exists for this service line item.  If not required by this implementation guide, do not send”   In the business scenario given, the type of bill is inpatient (11X) therefore sending a CPT (or other HCPCS) code that is not for a drug or biologic is not compliant with this situational rule.