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# | Location | File | Last Modified |
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1 | CPEE_v1_Build_7.zip\CPEE_v1_Build_7\Build 7 - Sprint 15\CPE001-121 Assistant Surgeons. When a procedure is submitted with an assistant surgeon modifier (80, 81, or 82) | Unit Test - User Story CPE001-121.docx | Tue Apr 24 15:18:38 2018 UTC |
2 | CPEE_v1_Build_7.zip\CPEE_v1_Build_7\Build 7 - Sprint 15\CPE001-121 Assistant Surgeons. When a procedure is submitted with an assistant surgeon modifier (80, 81, or 82) | Unit Test - User Story CPE001-121.docx | Tue Apr 24 18:28:33 2018 UTC |
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1 | Unit Test - User Sto ry CPE001- 121 | |
2 | ||
3 | Assistant Surgeons. When a pro cedure is submitted with an as sistant su rgeon modi fier (80, 81, or 82) | |
4 | ||
5 | ||
6 | Assistant Surgeons. When a pro cedure is submitted with an as sistant su rgeon modi fier (80, 81, or 82) , claim re view softw are, AI (A rtificial Intelligen ce) determ ines wheth er that pr ocedure al ways, some times, or never requ ires an as sistant su rgeon. If the deter mination i s always, the modifi ed code wi ll pay, if the deter mination i s never, t he modifie d code wil l reject, if the det ermination is someti mes, clini cal review of the pr ocedure is necessary . | |
7 | ||
8 | 16% of the allowed a mount | |
9 | ||
10 | ||
11 | Convert IC D-9-CM Dia gnosis 844 .2 to ICD- 10-CM | |
12 | ICD-9-CM 8 44.2 conve rts approx imately to : | |
13 | •2018 ICD- 10-CM S83. 509A Sprai n of unspe cified cru ciate liga ment of un specified knee, init ial encoun ter | |
14 | ||
15 | ||
16 | MODIFIER 8 0 | |
17 | ||
18 | ||
19 | ||
20 | PDI: 20180 6103000192 Page #: 1 Img #: 1 Assign ment: | |
21 | Vendor: IN TRALIGN CA PHYS ASSI STANTS Ben eficiary: SANDER-SIR OIS,MARYKA Y | |
22 | [OUTPATIEN T E/E SCRE EN - BILL/ INVOICE] | |
23 | OHI TOC: 1 - NO OHI OHI Edit TOC: | |
24 | DOS POS I CD REV SVCS/ND C MODS UNT/QTY AMOUNT P/R BAL | |
25 | 1 03/14/ 18 OP S83 .509A | |
26 | 2 03/14/ 18 OP 2 9888 80 1 5000.00 | |
27 | ||
28 | ||
29 | ||
30 | ||
31 | ||
32 | ||
33 | TOTALS 5,000.00 0.00 | |
34 | KNEE ARTHR OSCOPY/SUR GERY | |
35 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
36 | ||
37 | ||
38 | ||
39 | ||
40 | ||
41 | [ Edit Claim Data Scre en] | |
42 | ||
43 | ||
44 | PDI# 20180 6103000192 Related C laims: | |
45 | ||
46 | No. Claim # RO Cl # Bene Typ Vendor D.O.S D/C | |
47 | --- ----- -- ----- -- ---- ---------- - --- ---------- ------- --- --- | |
48 | ||
49 | 1) RLT81 87 SAND ER-SIROIS, M OUT INTRALIGN 3/14/20 18 | |
50 | ||
51 | ||
52 | DUZ: 0 Health A dministrat ion Center Page: 1 | |
53 | Date: MAR 16, 2018 Post-Pro cessing Cl aim Report | |
54 | Time: 851 | |
55 | ||
56 | PDI: 201806103 000192- BATCH: Cl aim #: RLT 8187 | |
57 | EIN: 710890443 - -cc S tatus: Pay ment Req. | |
58 | Program: CHAMPVA | |
59 | Vendor: INTRALIGN CA PHYS A S Type: Out patient | |
60 | Pay Prov?: Yes Ser/Admis Date: MAR 14,2018 | |
61 | Sponsor: SIROIS,PA UL D Comp. Date: | |
62 | Bene: SANDER-SI ROIS,MARYK AY POS: OUT PATIENT HO S | |
63 | Bene Sex: F Bene DOB: 05/27/63 P L ZIP: 920 56 | |
64 | ||
65 | ||
66 | ||
67 | ||
68 | Press <RET URN> to co ntinue, <^ > to exit. | |
69 | ||
70 | DX's/Px's/ NDC's P/L Unt/Qty Total Chg TotalAA Mcai d O HI #1 PD OHI #1 P R Deduc t Pa yments AI Reas | |
71 | AlwUnt Chg/Unt AA/Unt A ddl OHI OHI PR B al Cst S hare | |
72 | ---------- --------- ------- ---------- - ------- ---- ---- ------- - ---------- -------- --- ----- ------ -- --------- -- ---- | |
73 | S83.509A 1 AC | |
74 | ||
75 | 29888-80 1 5,000.0 0 16 5.08 0.00 123.81 AC 174 | |
76 | 1 5,000.0 0 16 5.08 41.27 | |
77 | ||
78 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ----- | |
79 | Totals: 5,000.0 0 16 5.08 0.00 123.81 | |
80 | 41.27 | |
81 | ||
82 | ||
83 | Press <RET URN> to Co ntinue, <^ > to exit. | |
84 | ||
85 | ||
86 | ||
87 | Tot al Charges Billed: 5,00 0.00 CITI Maximum Re imbursemen t Rate: N/ A | |
88 | Calculated Allowable Amount: 16 5.08 MEDICAID Amount: N/ A | |
89 | A mount Appl ied to Ded uctible: 0.00 Am ount Paid by TPL: N/ A | |
90 | Cos t Share Cr edited to Cat Cap: 4 1.27 Amoun t Reversed from Dedu ctible: N/ A | |
91 | Amount Paid by O ther Insur ance(s): N/A Am ount Rever sed from C at Cap: N/ A | |
92 | Pa tient Resp onsibility Amount: N/A Amount Red uced from Previous P ayment: N/ A | |
93 | Amount Pa id by Bene ficiary to Vendor: 0.00 L ast PDI Pa yment Diff erence: 0.0 0 | |
94 | Total Amount to be PAID o n claim: 12 3.81 Total Paym ent for Cu rrent PDI# 201806103 000192: +123.8 1 | |
95 | Amou nt PAID to Vendor: 12 3.81 | |
96 | Amount PA ID to Bene ficiary: 0.00 | |
97 | ||
98 | Press <RET URN> to Co ntinue, <^ > to exit. | |
99 | ||
100 | ||
101 | CHAM PVA Benefi ciary Dedu ctible 201 8: 50.00 (satisfied ) | |
102 | CHAMPVA F amily Dedu ctible 201 8: 50.00 | |
103 | CHAMP VA Family Catastroph ic Cap 201 8: 505.86 | |
104 | ||
105 | Press <RET URN> to Co ntinue, <^ > to exit. | |
106 | ||
107 | ||
108 | ||
109 | Actions fo r Claim: | |
110 | ||
111 | 1) SNA CAPPS (Pen ding Batch Process) 2) Clai mCheck (Co mplete) | |
112 | ||
113 | ||
114 | Claim Reas ons: 319 - CFR 17.272(B)( 3) REQUIRE S PROVIDER TO ACCEPT CHAMPVA A LLOWABLE A S FULL PAY MENT. | |
115 | 322 - COST SHARE FOR CLAIM MAY NOT ALWAY S BE PATIE NT LIABILI TY; OHI / CAT CAP MA Y IMPACT. | |
116 | 356 - REMI NDER - MAI L CLAIMS T O: CHAMPVA , PO Box 4 69064, DEN VER, CO 80 246-9064 | |
117 | 371 - WHEN RESUBMITT ING CLAIMS YOU MUST ATTACH THE CHAMPVA E OB FOR PRO PER PROCES SING. | |
118 | ||
119 | Line Item Reasons: 174 - PAYM ENT BASED ON 16% OF ALLOWABLE CHARGE FOR PRIMARY S URGEON. | |
120 | ||
121 | ||
122 | Press <RET URN> to co ntinue. | |
123 | ||
124 | ||
125 | ||
126 | ||
127 | C MAC Data | |
128 | ||
129 | ||
130 | Z ip Code: 92056 | |
131 | CHA MPUS Local ity No.: 416 | |
132 | C PT Code: 29888 | |
133 | CMAC Da ta Year: 18 | |
134 | ||
135 | F acility Non-Facili ty Profe ssional Technical | |
136 | - Physicia n $ 1031.73 $ 1031.73 | |
137 | - Non-Phys ician $ 876.97 $ 876.97 | |
138 | ||
139 | <RETURN> t o continue : | |
140 | ||
141 | ||
142 | ||
143 | HADR1TSVR: HADTST>W 1 031.73*.16 | |
144 | ||
145 | 165.0768 | |
146 | ||
147 | ||
148 | ||
149 | ||
150 | ||
151 | ||
152 | MODIFIER 8 1 | |
153 | ||
154 | ||
155 | PDI# 20180 6103000190 Related C laims: | |
156 | ||
157 | No. Claim # RO Cl # Bene Typ Vendor D.O.S D/C | |
158 | --- ----- -- ----- -- ---- ---------- - --- ---------- ------- --- --- | |
159 | ||
160 | 1) RLT81 85 SAND ER-SIROIS, M OUT INTRALIGN 3/16/20 18 | |
161 | ||
162 | ||
163 | DUZ: 0 Health A dministrat ion Center Page: 1 | |
164 | Date: MAR 16, 2018 Post-Pro cessing Cl aim Report | |
165 | Time: 750 | |
166 | ||
167 | PDI: 201806103 000190- BATCH: Cl aim #: RLT 8185 | |
168 | EIN: 710890443 - -cc S tatus: Pay ment Req. | |
169 | Program: CHAMPVA | |
170 | Vendor: INTRALIGN CA PHYS A S Type: Out patient | |
171 | Pay Prov?: Yes Ser/Admis Date: MAR 16,2018 | |
172 | Sponsor: SIROIS,PA UL D Comp. Date: | |
173 | Bene: SANDER-SI ROIS,MARYK AY POS: OUT PATIENT HO S | |
174 | Bene Sex: F Bene DOB: 05/27/63 P L ZIP: 920 56 | |
175 | ||
176 | ||
177 | ||
178 | ||
179 | Press <RET URN> to co ntinue, <^ > to exit. | |
180 | ||
181 | DX's/Px's/ NDC's P/L Unt/Qty Total Chg TotalAA Mcai d O HI #1 PD OHI #1 P R Deduc t Pa yments AI Reas | |
182 | AlwUnt Chg/Unt AA/Unt A ddl OHI OHI PR B al Cst S hare | |
183 | ---------- --------- ------- ---------- - ------- ---- ---- ------- - ---------- -------- --- ----- ------ -- --------- -- ---- | |
184 | S83.509A 1 AC | |
185 | ||
186 | 29888-81 1 5,000.0 0 16 5.08 0.00 123.81 AC 174 | |
187 | 1 5,000.0 0 16 5.08 41.27 | |
188 | ||
189 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ----- | |
190 | Totals: 5,000.0 0 16 5.08 0.00 123.81 | |
191 | 41.27 | |
192 | ||
193 | ||
194 | Press <RET URN> to Co ntinue, <^ > to exit. | |
195 | ||
196 | ||
197 | ||
198 | Tot al Charges Billed: 5,00 0.00 CITI Maximum Re imbursemen t Rate: N/ A | |
199 | Calculated Allowable Amount: 16 5.08 MEDICAID Amount: N/ A | |
200 | A mount Appl ied to Ded uctible: 0.00 Am ount Paid by TPL: N/ A | |
201 | Cos t Share Cr edited to Cat Cap: 4 1.27 Amoun t Reversed from Dedu ctible: N/ A | |
202 | Amount Paid by O ther Insur ance(s): N/A Am ount Rever sed from C at Cap: N/ A | |
203 | Pa tient Resp onsibility Amount: N/A Amount Red uced from Previous P ayment: N/ A | |
204 | Amount Pa id by Bene ficiary to Vendor: 0.00 L ast PDI Pa yment Diff erence: 0.0 0 | |
205 | Total Amount to be PAID o n claim: 12 3.81 Total Paym ent for Cu rrent PDI# 201806103 000190: +123.8 1 | |
206 | Amou nt PAID to Vendor: 12 3.81 | |
207 | Amount PA ID to Bene ficiary: 0.00 | |
208 | ||
209 | Press <RET URN> to Co ntinue, <^ > to exit. | |
210 | ||
211 | ||
212 | CHAM PVA Benefi ciary Dedu ctible 201 8: 50.00 (satisfied ) | |
213 | CHAMPVA F amily Dedu ctible 201 8: 50.00 | |
214 | CHAMP VA Family Catastroph ic Cap 201 8: 423.32 | |
215 | ||
216 | Press <RET URN> to Co ntinue, <^ > to exit. | |
217 | ||
218 | ||
219 | ||
220 | Actions fo r Claim: | |
221 | ||
222 | 1) SNA CAPPS (Pen ding Batch Process) 2) Clai mCheck (Co mplete) | |
223 | ||
224 | ||
225 | Claim Reas ons: 319 - CFR 17.272(B)( 3) REQUIRE S PROVIDER TO ACCEPT CHAMPVA A LLOWABLE A S FULL PAY MENT. | |
226 | 322 - COST SHARE FOR CLAIM MAY NOT ALWAY S BE PATIE NT LIABILI TY; OHI / CAT CAP MA Y IMPACT. | |
227 | 356 - REMI NDER - MAI L CLAIMS T O: CHAMPVA , PO Box 4 69064, DEN VER, CO 80 246-9064 | |
228 | 371 - WHEN RESUBMITT ING CLAIMS YOU MUST ATTACH THE CHAMPVA E OB FOR PRO PER PROCES SING. | |
229 | ||
230 | Line Item Reasons: 174 - PAYM ENT BASED ON 16% OF ALLOWABLE CHARGE FOR PRIMARY S URGEON. | |
231 | ||
232 | ||
233 | ||
234 | C MAC Data | |
235 | ||
236 | ||
237 | Z ip Code: 92056 | |
238 | CHA MPUS Local ity No.: 416 | |
239 | C PT Code: 29888 | |
240 | CMAC Da ta Year: 18 | |
241 | ||
242 | F acility Non-Facili ty Profe ssional Technical | |
243 | - Physicia n $ 1031.73 $ 1031.73 | |
244 | - Non-Phys ician $ 876.97 $ 876.97 | |
245 | ||
246 | <RETURN> t o continue : | |
247 | ||
248 | ||
249 | ||
250 | HADR1TSVR: HADTST>W 1 031.73*.16 | |
251 | ||
252 | 165.0768 | |
253 | ||
254 | ||
255 | ||
256 | ||
257 | ||
258 | ||
259 | MODIFIER 8 2 | |
260 | ||
261 | ||
262 | PDI# 20180 6103000191 Related C laims: | |
263 | ||
264 | No. Claim # RO Cl # Bene Typ Vendor D.O.S D/C | |
265 | --- ----- -- ----- -- ---- ---------- - --- ---------- ------- --- --- | |
266 | ||
267 | 1) RLT81 86 SAND ER-SIROIS, M OUT INTRALIGN 3/16/20 18 | |
268 | ||
269 | ||
270 | ||
271 | OU TPATIENT D ATA SCREEN | |
272 | ||
273 | DOS: MAR 1 6, 2018 Tota l Charges: $ 5000.0 0 TOTA L PR BAL:$ 0.00 | |
274 | ||
275 | DXS PXS/NDC MOD IFIERS UN T/QTY DESC RIPTION AMOUNT P/R BAL | |
276 | 1 S83.509 A SPRA IN UNS C | |
277 | 2 29888 82 1 KNEE ARTHROS 5000.00 | |
278 | ||
279 | ||
280 | DUZ: 0 Health A dministrat ion Center Page: 1 | |
281 | Date: MAR 16, 2018 Post-Pro cessing Cl aim Report | |
282 | Time: 841 | |
283 | ||
284 | PDI: 201806103 000191- BATCH: Cl aim #: RLT 8186 | |
285 | EIN: 710890443 - -cc S tatus: Pay ment Req. | |
286 | Program: CHAMPVA | |
287 | Vendor: INTRALIGN CA PHYS A S Type: Out patient | |
288 | Pay Prov?: Yes Ser/Admis Date: MAR 16,2018 | |
289 | Sponsor: SIROIS,PA UL D Comp. Date: | |
290 | Bene: SANDER-SI ROIS,MARYK AY POS: OUT PATIENT HO S | |
291 | Bene Sex: F Bene DOB: 05/27/63 P L ZIP: 920 56 | |
292 | ||
293 | ||
294 | ||
295 | ||
296 | Press <RET URN> to co ntinue, <^ > to exit. | |
297 | ||
298 | DX's/Px's/ NDC's P/L Unt/Qty Total Chg TotalAA Mcai d O HI #1 PD OHI #1 P R Deduc t Pa yments AI Reas | |
299 | AlwUnt Chg/Unt AA/Unt A ddl OHI OHI PR B al Cst S hare | |
300 | ---------- --------- ------- ---------- - ------- ---- ---- ------- - ---------- -------- --- ----- ------ -- --------- -- ---- | |
301 | S83.509A 1 AC | |
302 | ||
303 | 29888-82 1 5,000.0 0 16 5.08 0.00 123.81 AC 174 | |
304 | 1 5,000.0 0 16 5.08 41.27 | |
305 | ||
306 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ----- | |
307 | Totals: 5,000.0 0 16 5.08 0.00 123.81 | |
308 | 41.27 | |
309 | ||
310 | ||
311 | Press <RET URN> to Co ntinue, <^ > to exit. | |
312 | ||
313 | ||
314 | ||
315 | Tot al Charges Billed: 5,00 0.00 CITI Maximum Re imbursemen t Rate: N/ A | |
316 | Calculated Allowable Amount: 16 5.08 MEDICAID Amount: N/ A | |
317 | A mount Appl ied to Ded uctible: 0.00 Am ount Paid by TPL: N/ A | |
318 | Cos t Share Cr edited to Cat Cap: 4 1.27 Amoun t Reversed from Dedu ctible: N/ A | |
319 | Amount Paid by O ther Insur ance(s): N/A Am ount Rever sed from C at Cap: N/ A | |
320 | Pa tient Resp onsibility Amount: N/A Amount Red uced from Previous P ayment: N/ A | |
321 | Amount Pa id by Bene ficiary to Vendor: 0.00 L ast PDI Pa yment Diff erence: 0.0 0 | |
322 | Total Amount to be PAID o n claim: 12 3.81 Total Paym ent for Cu rrent PDI# 201806103 000191: +123.8 1 | |
323 | Amou nt PAID to Vendor: 12 3.81 | |
324 | Amount PA ID to Bene ficiary: 0.00 | |
325 | ||
326 | Press <RET URN> to Co ntinue, <^ > to exit. | |
327 | ||
328 | ||
329 | CHAM PVA Benefi ciary Dedu ctible 201 8: 50.00 (satisfied ) | |
330 | CHAMPVA F amily Dedu ctible 201 8: 50.00 | |
331 | CHAMP VA Family Catastroph ic Cap 201 8: 464.59 | |
332 | ||
333 | Press <RET URN> to Co ntinue, <^ > to exit. | |
334 | ||
335 | ||
336 | ||
337 | Actions fo r Claim: | |
338 | ||
339 | 1) SNA CAPPS (Pen ding Batch Process) 2) Dupl icate Clai m (Accepte d) | |
340 | 3) Clai mCheck (Co mplete) | |
341 | ||
342 | ||
343 | Claim Reas ons: 319 - CFR 17.272(B)( 3) REQUIRE S PROVIDER TO ACCEPT CHAMPVA A LLOWABLE A S FULL PAY MENT. | |
344 | 322 - COST SHARE FOR CLAIM MAY NOT ALWAY S BE PATIE NT LIABILI TY; OHI / CAT CAP MA Y IMPACT. | |
345 | 356 - REMI NDER - MAI L CLAIMS T O: CHAMPVA , PO Box 4 69064, DEN VER, CO 80 246-9064 | |
346 | 371 - WHEN RESUBMITT ING CLAIMS YOU MUST ATTACH THE CHAMPVA E OB FOR PRO PER PROCES SING. | |
347 | ||
348 | Line Item Reasons: 174 - PAYM ENT BASED ON 16% OF ALLOWABLE CHARGE FOR PRIMARY S URGEON. | |
349 | ||
350 | ||
351 | Press <RET URN> to co ntinue. | |
352 | ||
353 | ||
354 | C MAC Data | |
355 | ||
356 | ||
357 | Z ip Code: 92056 | |
358 | CHA MPUS Local ity No.: 416 | |
359 | C PT Code: 29888 | |
360 | CMAC Da ta Year: 18 | |
361 | ||
362 | F acility Non-Facili ty Profe ssional Technical | |
363 | - Physicia n $ 1031.73 $ 1031.73 | |
364 | - Non-Phys ician $ 876.97 $ 876.97 | |
365 | ||
366 | <RETURN> t o continue : | |
367 | ||
368 | ||
369 | HADR1TSVR: HADTST>W 1 031.73*.16 | |
370 | ||
371 | 165.0768 | |
372 | ||
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