Change Request Detail
No.
1141
Date
2/4/2011
Submitter
Type of Request
Institutional Claim (UB-92)
Status
DSMO Process Completed
Business Reason
The patient reason for visit for all outpatient claims is not valid for many outpatient claims where a service is performed while the patient is not visiting the institution, e.g. outside lab work.

The UB04 guide has the list of criteria for valid services that require the reason for visit and the payers do not require it for many services. The burden of work to either collect the data accurately or simply fudge the data by selecting the DX code that the Doctor submits is wasteful when the data is not used nor is it even applicable.
Suggestion
Make the patient reason for visit situational for outpatient claims. (HI segment in loop 2300)
DSMO Category
D
Recommendation
Disapprove.  The data element is already situational for certain outpatient claims.   Future versions of the TR3 clarify the situational usage note.

The determination of Inpatient vs. Outpatient designation as defined by the NUBC Manual is documented in the front matter in Section 1.5 and 1.12.6 of the TR3.  In addition, ASC X12 has issued an RFI (1256) that clarifies that Patient’s Reason for Visit is not required on ALL outpatient claims, but rather on certain outpatient claims as directed by the NUBC billing manual:

Not required on any claim except for 013x, 085x and 078x when:

a) Priority (Type) of Admission/Visit Codes
1,2, or 5 are reported

AND

b) Revenue Codes 045x, 0516, 0526, or 0762 are reported.

May be reported on all other 013x, 078x and 085x types of bills at submitter’s discretion when this information provides additional information to support medical necessity.
Appeal Recommendation