Bundling (Code Editing) Example (HealthLink)
Correct coding (bundling) or code review / editing will be communicated in HealthLink’s outbound priced claims for professional claims (1500s) only, and for business blocks with code review / editing enabled (most business blocks). The following is an example to demonstrate how the service lines will be communicated for code bundling.
After code review – on line 3, CPT code excluded by code review and billed amount was combined into line 2 ($83 + $142).
The main elements of 837 are created (Sensitive in formation is replaced with xxxxx’s) CLM*xxxxxx*354***11::1*Y*A*Y*Y~
total billed amount for claim loop 2320 – other subscriber information added loop for compliance
This amount is calculated as follows: total billed (clm02) – (total allowed (AMT02) + sum of line item CAS (CAS03) segments)
$354 – ($131.55 + $142)
AMT*D*131.55~ – total allowed for claim
OI***Y*B**Y~ 2330A and 2330B
Added these loops for compliance
N3*1303 W MAIN ST~
LX*1~ no change
hcp02, value of 04 indicates bundled pricing
zero allowed amount
Loop 2430 line adjudication information – added loop for compliance
CAS*CO*97*142~ – amount adjusted
LX*4~ – no change
It is necessary for HealthLink to include an “Other Payor” loop, Loop 2330B, in order to make the claim appear as a secondary claim and satisfy the HIPAA compliant edits. If this truly were a secondary claim, HealthLink would indicate the secondary payor information in this segment and send the claim to the secondary payor. Because HealthLink is not sending the claim to the secondary payor, we use the default text “REPRICER”, in order to communicate HealthLink as the repricer.
To summarize, the code review/editing will illustrate (within the outbound electronic claim):
HealthLink as the “Repricer”. The original claim line items with original units and billed amounts for each service line. The correct code or codes with the correct allowed amount, and original billed amount. The net effect will be to show the original billed amounts and codes, the correct code(s) with allowed amounts corresponding with each.
To learn more about HIPAA EDI and become a certified EDI Professional, please visit our course schedule page.