DRG and Deductible Info Not Showing up in CSV file
Philip
Print it appears as though the DRG amount is not populating the same
column in the X12 csv file. Also I would like to see the DRG Operating
Capital amount which is in the same segment:
MIA*0***5741.04*MA01*373.07**406.92*406.92******2*4961.05~
5741.04 is the DRG Amount
DRG Operating Capital is the sum of 373.07 and 406.92 = 779.99
This is what is looks like in PC Print; 779.99=DRG/OPER/CAP
X12 is also not picking up all the deductibles in the CSV export. It
is picking up the first CAS line but not the second:
CAS*CO*45*3134.32~ This is the claim adjustment
CAS*PR*1*1100*0~ This is the cash deductable- Could this also
be : PATRESPONSIBLE column which is not populating.
The CSV file's CLMADJAMT# columns are all populated with the first CAS
segment above.
Com1 Software
We will be adding the DRG fields you are looking for in the next
release planned fro sometime this week.
Here is a link that may help with some of your questions
http://com1software.com/c1d0f431.htm#0612
Regarding:
PATRESPONSIBLE
Patient Responsibility
Location : CLP Segment, Element 5
Regarding the Claim adjustments:
I will be running some tests and will let you know what I find.
Information regarding the updates is posted here:
http://groups.google.com/group/com1software
Thanks
Dave
Com1 Software
We have added the MIA fields into the latest release.
http://groups.google.com/group/com1software?hl=en
Below is a snippet that can be added to your c1835.xml map.
Let me know if we missed anything.
Regarding the CAS issues, we started looking at the problem
but ran out of time to correct it in this release. We hope to have it
corrected in the next release.
Thanks
Dave
<FIELD>MIACOVDVC</FIELD>
<FIELD>MIAOPOUTAMT</FIELD>
<FIELD>MIALIFPSYDAYS</FIELD>
<FIELD>MIADRGAMT</FIELD>
<FIELD>MIAREMARK1</FIELD>
<FIELD>MIASHAREAMT</FIELD>
<FIELD>MIAMSPPASSAMT</FIELD>
<FIELD>MIAPPSCAPAMT</FIELD>
<FIELD>MIAFSPDRGAMT</FIELD>
<FIELD>MIAHSPDRGAMT</FIELD>
<FIELD>MIADHSDRGAMT</FIELD>
<FIELD>MIAOLDCAPAMT</FIELD>
<FIELD>MIAIMEAMT</FIELD>
<FIELD>MIAOHSDRG</FIELD>
<FIELD>MIACOSTRPTDATCNT</FIELD>
<FIELD>MIAOFSDRG</FIELD>
<FIELD>MIAPPSCAPOUTAMT</FIELD>
<FIELD>MIAINDTEACHAMT</FIELD>
<FIELD>MIANONPAYPROAMT</FIELD>
<FIELD>MIAREMARK2</FIELD>
<FIELD>MIAREMARK3</FIELD>
<FIELD>MIAREMARK4</FIELD>
<FIELD>MIAREMARK5</FIELD>
<FIELD>MIACAPEXCPAMT</FIELD>
On Jan 5, 8:46 am, Com1 Software <informat...@com1software.com> wrote:
> Philip,
>
> We will be adding the DRG fields you are looking for in the next
> release planned fro sometime this week.
>
Philip
the 835 text file there appears to be CAS segments in different areas
of each record. The inpatients CAS segments are between the CLP and
the NM1 Segments. I am assuming because they pay by DRG and not by
procedures so the total adjustment is rolled up into a couple CAS
segments. Outpatient CAS records are down in the segments that detail
out the outpatient procedures. Is there a way of differentiating
between inpatient CAS and outpatient CAS? I see that there are claim
adjustments for each procedure so that may not be an issue but what
about inpatient CAS in the output file. The CAS corrections look
perfect for inpatient but when the record changes to outpatient the
first CAS record is populated once for the first adjustment and then
the procedure adjustment are the same info. The reason I am so picky
is that I need to be able to tie back to what the claim total is. I
need to see all the adjustments that make up what is reported and what
the reimbursement actually is. Thanks for being so responsive.
Inpatient
CLP......
CAS*CO*45*17204.15~
CAS*PR*1*1100*0~
NM1........
Outpatient record
CLP......
NM1
SVC*HC>76536*255*57.41*0402*1~
DTM*472*20100518~
CAS*CO*45*161.39~
CAS*PR*2*36.2~
REF*1S*00266~
> We have added the MIA fields into the latest release.http://groups.google.com/group/com1software?hl=en
infor...@com1software.com
With regard to inpatient vs outpatient and the CAS segments, they are treated identical. As
you mentioned there may be some segments used that will be used by inpatinet only.
I am not sure why you are having a problem. I will be glad to run tests to look for it however I
am not sure what to look for yet. One thing that does come to mind is that two CAS segments
as described cannot have any other segments between them, that would cause it to fail.
Let me know.
Thanks
Dave
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Philip LaRochelle
From: "infor...@com1software.com" <infor...@com1software.com>
To: x12-u...@googlegroups.com
Sent: Tue, January 25, 2011 3:00:12 PM
Subject: Re: DRG and Deductible Info Not Showing up in CSV file
> For more options, visit this group at
> http://groups.google.com/group/x12-utility?hl=en.
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Philip LaRochelle
SERVICE ADJUSTMENT
Loop: 2110 — SERVICE PAYMENT INFORMATION
Usage: SITUATIONAL
Repeat: 99
1208 Notes: 1. This CAS segment is optional and is intended to reflect reductions in
payment due to adjustments particular to a specific service in the
claim. An example of this level of CAS is the reduction for the part of
the service charge that exceeds the usual and customary charge for
the service. See 2.2.1, Balancing, and 2.2.4, Claim Adjustment and
Service Adjustment Segment Theory, for additional information.
1936
2. A single CAS segment contains six repetitions of the “adjustment
trio” composed of adjustment reason code, adjustment amount, and
adjustment quantity. These six adjustment trios are used to report up
to six adjustments related to a particular Claim Adjustment Group
Code (CAS01). The first adjustment is reported in the first adjustment
trio (CAS02-CAS04). If there is a second non-zero adjustment, it is
reported in the second adjustment trio (CAS05-CAS07), and so on
through the sixth adjustment trio (CAS17-CAS19).
1308 Example: CAS]CO]A2]20~
STANDARD
CAS Claims Adjustment
Level: Detail
Position: 090
Loop: 2110
Requirement: Optional
Max Use: 99
Purpose: To supply adjustment reason codes and amounts as needed for an entire claim
or for a particular service within the claim being paid
From: Philip LaRochelle <plar...@yahoo.com>
To: x12-u...@googlegroups.com
Sent: Tue, January 25, 2011 5:54:20 PM
Subject: Re: DRG and Deductible Info Not Showing up in CSV file
From: "infor...@com1software.com" <infor...@com1software.com>
To: x12-u...@googlegroups.com
Sent: Tue, January 25, 2011 3:00:12 PM
Subject: Re: DRG and Deductible Info Not Showing up in CSV file
> For more options, visit this group at
> http://groups.google.com/group/x12-utility?hl=en.
>
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Philip LaRochelle
Would it be possible to use the segment MIA= Medicare Inpatient adjudication and the MOA=Medicare Outpatient adjudication segment as some kind of indicator of where to place the CAS information in the CSV file?
If anything could it be possible to use the two to indicate in a record if a patient is an inpatient or outpatient. PATIENT TYPE = I or O as a possible column.
Thanks again for all your help.
Com1 Software
Regarding the PATIENT TYPE = I or O, Yes, we can do that and will
plan it for the next release.
Regarding the " where to place the CAS information in the CSV file"
The CAS would be in it's set column are you looking have it change
positions
from being column 10 to column 20?
Thanks
Dave
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Com1 Software
Regarding the CLMADJAMT1 and the issue of "A single CAS segment
those adjustments.
Regarding the PROCADJAMT01, I will be running some test to see what is
going on and will let you know.
Thanks
Dave
> > For more options, visit this group at
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Com1 Software
The CLMADJAMT1 is claim level and the PROCADJAMT01 is service line
level.
I will be running some tests to look at what you have described.
Thanks
Dave
On Jan 25, 5:54 pm, Philip LaRochelle <plaroc...@yahoo.com> wrote:
> Is there a difference between the CLMADJAMT1 and PROCADJAMT01 columns. In my
> thinking CLMADJAMT1 is for inpatients and PROCADJAMT01 would be for outpatient.
> I am seeing the same number in both columns for outpatients.
>
> ________________________________
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Com1 Software
Just to keep you up to date.
In the latest release Version 1.17A-28 I did some work that seems to
make PROCADJAMT01 work correctly.
PROCADJAMT01 will pick up the first CAS in the first service line.
We will be adding new fields in in the next release like
PROCADJAMT01.1 and PROCADJAMT01.2, ect
to pick up additional service line level CAS data.
Thanks
Dave
> > For more options, visit this group at
> >http://groups.google.com/group/x12-utility?hl=en.
>
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Philip LaRochelle
I am on a Windows 7 64 bit machine. Do you think that could be the problem of not being able to install the updates right from the application? Again, the installer will not launch after downloading version 1.17A-28.
Thanks,
Phil
From: Com1 Software <infor...@com1software.com>
To: X12 Utility <x12-u...@googlegroups.com>
Sent: Fri, January 28, 2011 11:48:36 AM
Subject: Re: Fw: DRG and Deductible Info Not Showing up in CSV file
> > For more options, visit this group at
> >http://groups.google.com/group/x12-utility?hl=en.
>
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Philip LaRochelle
I just wanted to show you what I am looking at:
The attached file is a snippet of information from an 835 file exported by X12 to a CSV file.
As the patients change from inpatient to outpatient the CSV file only picks up the first service level claim adjustment. Claim number 9 has about nine outpatient service level claim adjustments. The inpatient claims adjustments look great.
Thanks,
Phil.
P.S. I was able to upgrade the X12 from the software interface. I am working on the most recent version.
infor...@com1software.com
I ran a couple of tests here and things seem to be working ok in the latest version.
Below is the map I used to test.
I set up a new example # 17 on our examples page to test with.
Example 3 has a mix MOA and MIA claims as well however I have done my initial tests
with example 17 just to keep it simple.
http://com1software.com/c1054.htm
Let me know if you think we need to add or adjust anything in the example to test it better.
Since we have done a ton of work in that area you may want to make sure that you are on
the latest version.
http://groups.google.com/group/com1software
Thanks
Dave
<?xml version="1.0" encoding="ISO-8859-1"?>
<CONFIGURATION>
<FIELD>CLAIMPATCTL</FIELD>
<FIELD>PROCBILLEDAMT1</FIELD>
<FIELD>PROCADJGRPCODE1</FIELD>
<FIELD>PROCADJCODE1</FIELD>
<FIELD>PROCADJAMT1</FIELD>
<FIELD>PROCBILLEDAMT2</FIELD>
<FIELD>PROCADJGRPCODE2</FIELD>
<FIELD>PROCADJCODE2</FIELD>
<FIELD>PROCADJAMT2</FIELD>
<FIELD>PROCBILLEDAMT3</FIELD>
<FIELD>PROCADJGRPCODE3</FIELD>
<FIELD>PROCADJCODE3</FIELD>
<FIELD>PROCADJAMT3</FIELD>
</CONFIGURATION>
On 29 Jan 2011 at 18:06, Philip LaRochelle wrote:
>
> Dave,
> I just wanted to show you what I am looking at:
>
> The attached file is a snippet of information from an 835 file
> exported by X12 to a CSV file.
>
> As the patients change from inpatient to outpatient the CSV file
> only picks up the first service level
> claim adjustment. Claim number 9 has about nine outpatient service
> level claim adjustments. The
> inpatient claims adjustments look great.
>
> Thanks,
>
> Phil.
>
> P.S. I was able to upgrade the X12 from the software interface. I am
> working on the most recent
> version.
>
>
> From: Com1 Software <infor...@com1software.com>
> To: X12 Utility <x12-u...@googlegroups.com>
> Sent: Fri, January 28, 2011 11:48:36 AM
> Subject: Re: Fw: DRG and Deductible Info Not Showing up in CSV
> file
>
> Phil,
>
> Just to keep you up to date.
> In the latest release Version 1.17A-28 I did some work that seems
> to
> make PROCADJAMT01 work correctly.
>
> PROCADJAMT01 will pick up the first CAS in the first service line.
>
> We will be adding new fields in in the next release like
> PROCADJAMT01.1 and PROCADJAMT01.2, ect
> to pick up additional service line level CAS data.
>
> Thanks
> Dave
>
>
>
> On Jan 25, 8:33pm, Philip LaRochelle <plaroc...@yahoo.com> wrote:
> > I found this in a 835 file data set file. I think we are picking
> up the total
> > claim adjustment in CLMADJAMT1 but possible not the procedure or
> Service
> > Adjustment in PROCADJAMT01
> >
> > SERVICE ADJUSTMENT
> > Loop: 2110 - SERVICE PAYMENT INFORMATION
> > > x12-utility...@googlegroups.com.
> > > For more options, visit this group at
> > >http://groups.google.com/group/x12-utility?hl=en.
> >
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infor...@com1software.com
I am not sure if the 64 bit is the issue with the updates since we see it in windows xp as well.
I do find that windows 7 works better with the http and ftp functions of our software.
Just to let you and others know we are in the process of re-building some of the systems we
use to run the demos and deliver the updates so we may run into a few problems from time
to time till we get the new systems up in place.
As I may have mentioned to you, by using the logon information sent to you when you
purchased the software, you should be able to download an update. If you are still having
problems getting the update via your original logon we ask that you or anyone having that
same problem send us an email directly at infor...@com1software.com letting us know
you having that problem.
Please make sure to include the system number of the product in your email. We will then
email you back letting you know that we have reset your system.
Thanks
Dave
On 29 Jan 2011 at 15:14, Philip LaRochelle wrote:
>
> Thanks Dave for all your help and work. I think the progress is
> going very well.
>
> I am on a Windows 7 64 bit machine. Do you think that could be the
> problem of not being able to
> install the updates right from the application? Again, the installer
> will not launch after downloading
> version 1.17A-28.
>
> Thanks,
> Phil
>
>
> From: Com1 Software <infor...@com1software.com>
> To: X12 Utility <x12-u...@googlegroups.com>
> Sent: Fri, January 28, 2011 11:48:36 AM
> Subject: Re: Fw: DRG and Deductible Info Not Showing up in CSV
> file
>
> Phil,
>
> Just to keep you up to date.
> In the latest release Version 1.17A-28 I did some work that seems
> to
> make PROCADJAMT01 work correctly.
>
> PROCADJAMT01 will pick up the first CAS in the first service line.
>
> We will be adding new fields in in the next release like
> PROCADJAMT01.1 and PROCADJAMT01.2, ect
> to pick up additional service line level CAS data.
>
> Thanks
> Dave
>
>
>
> On Jan 25, 8:33pm, Philip LaRochelle <plaroc...@yahoo.com> wrote:
> > I found this in a 835 file data set file. I think we are picking
> up the total
> > claim adjustment in CLMADJAMT1 but possible not the procedure or
> Service
> > Adjustment in PROCADJAMT01
> >
> > SERVICE ADJUSTMENT
> > Loop: 2110 - SERVICE PAYMENT INFORMATION
> > > x12-utility...@googlegroups.com.
> > > For more options, visit this group at
> > >http://groups.google.com/group/x12-utility?hl=en.
> >
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Philip LaRochelle
I entered in the code listed in your below response, to bring in the procedure information. The claim info and procedure information is duplicating.
In the attached excel file. The cells colored yellow should not be in claim adjustments and only in procedure adjustments. Also some of the data is in both claims adj and procedure adj. All I am trying to do is break out coinsurance and deductible information to tie back to the total reimbursed. Would it be easier to just sum up the different adjustment codes instead of attempting to break them out separately?
1. Is the amount adjusted in this segment the patient’s responsibility?
Use code PR - Patient Responsibility.
2. Is the amount adjusted not the patient’s responsibility under any circumstances
due to either a contractual obligation between the provider and the
payer or a regulatory requirement?
Use code CO - Contractual Obligation.
An example of a contractual obligation might be a Participating Provider
Agreement.
3. In the payer’s opinion, is the amount in this segment not the responsibility of
the patient, without a supporting contract between the provider and the
payer?
Use code PI - Payer Initiated.
4. Is this claim the reversal of a previously reported claim or claim payment, indicated
by Claim Status Code = 22, Reversal of Previous Payment?
Use code CR - Correction and Reversals.
5. If no other category is appropriate, do the following:
Use code OA - Other Adjustment.
I am on version 1.17A-28
Thanks,
Phil
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Com1 Software
Sorry for the delay in getting back.
I ran another test and found the problem the you have mentioned.
In my other tests I was using our Parser to test.
Because so much of the code and functions are shared by our parser,
utility, and viewer, it is usually a safe bet
that if you fix something in one thing it is working in the others.
For some reason not in this case.
We will be looking at it and plan to address it in the next release.
Regarding your questions and points on the CAS adjustments, it sounds
like you have it pegged correctly.
Regarding Patient Responsibility don't forget there is an area in CLP
element 5 that should reflect what is in the CAS segmets
You also mentioned summing the adjustment codes. That is an
interesting idea that may be useful for verification. We will look at
the possibility of adding this type of field while we are in there
fixing our problems.
Also we have other fields available besides the ones you and I have
been discussing
Below are some examples:
http://com1software.com/c1d0f431.htm#0612
Thanks
Dave
PROCPAYAMT01
Procedure Pay Amount
Location : CAS Segment, Element 3
Element 1 Qualifier PR
PROCDEDUCTAMT01
Procedure Deductable Amount
Location : CAS Segment, Element 1
Element 1 Qualifier PR
PROCCOINSAMT01
Procedure Coinsurance Amount Amount
Location : CAS Segment, Element 2
Element 1 Qualifier PR
PROCCOADJAMT01
Location : CAS Segment, Element 3
Element 1 Qualifier CO
PROCPROTHERAM01
Location : CAS Segment, Element 2,5
Element 1 Qualifier PR
PROCCOPAYAMT01
Location : CAS Segment, Element 3
Element 1 Qualifier PR
> To: x12-u...@googlegroups.com
> Subject: Re: Fw: DRG and Deductible Info Not Showing up in CSV file
>
> Phil,
>
> I ran a couple of tests here and things seem to be working ok in the latest
> version.
>
> Below is the map I used to test.
>
> I set up a new example # 17 on our examples page to test with.
> Example 3 has a mix MOA and MIA claims as well however I have done my initial
> tests
> test it better.
>
> Since we have done a ton of work in that area you may want to make sure that you
> are on
>
>
> read more »
>
> snippet2.xls
> 63KViewDownload
Com1 Software
I appreciate all your help with this.
We have made an improvement where we support the use of a decimal
point and an additional number in the following fields
PROCADJGRPCODE
PROCADJCOD
PROCADJAMT
Below is an example of how to use it.
Thanks
Dave
<?xml version="1.0" encoding="ISO-8859-1"?>
<CONFIGURATION>
<FIELD>CLAIMPATCTL</FIELD>
<FIELD>PROCBILLEDAMT1</FIELD>
<FIELD>PROCADJCODE1.1</FIELD>
<FIELD>PROCADJAMT1.1</FIELD>
<FIELD>PROCADJGRPCODE1.2</FIELD>
<FIELD>PROCADJCODE1.2</FIELD>
<FIELD>PROCADJAMT1.2</FIELD>
<FIELD>PROCADJGRPCODE1.3</FIELD>
<FIELD>PROCADJCODE1.3</FIELD>
<FIELD>PROCADJAMT1.3</FIELD>
<FIELD>PROCBILLEDAMT2</FIELD>
<FIELD>PROCADJGRPCODE2.1</FIELD>
<FIELD>PROCADJCODE2.1</FIELD>
<FIELD>PROCADJAMT2.1</FIELD>
<FIELD>PROCADJGRPCODE2.2</FIELD>
<FIELD>PROCADJCODE2.2</FIELD>
<FIELD>PROCADJAMT2.2</FIELD>
<FIELD>PROCBILLEDAMT3</FIELD>
<FIELD>PROCADJGRPCODE3.1</FIELD>
<FIELD>PROCADJCODE3.1</FIELD>
<FIELD>PROCADJAMT3.1</FIELD>
<FIELD>PROCADJGRPCODE3.2</FIELD>
<FIELD>PROCADJCODE3.2</FIELD>
<FIELD>PROCADJAMT3.2</FIELD>
</CONFIGURATION>
On Feb 9, 10:35 am, Com1 Software <informat...@com1software.com>
wrote:
> Phil,
>
>
> read more »
Philip LaRochelle
Did version 1.17B-10 fix the below issue? I ran my file through and am seeing procedure adjustments in the claim adjustment fields. MOAMIATYPE works great.
I have attached a snippet of the X-12 Utility CSV file output.
Thanks,
Phil.
P.S. When we get this right you might have a fluffy of X-12 utility sales. Certain hospital clients are looking to this application instead of using our services. They will still need the xml file to retrieve what they are looking for. Good for you and still good for us.
Com1 Software
Good to hear about the MOAMIATYPE.
Yes, it should fix most of the issues we have been discussing.
I noticed in your field columns for PROCADJGRPCODE1, PROCADJCODE1,
and PROCADJAMT1 you do not have any decimal points and additional
numbers in them. The number to the right of the decimal represents the
iteration of the CAS within the service line, the number to the left
of the decimal point is the service line number. You can use the
PROCADJGRPCODE1, PROCADJCODE1, and PROCADJAMT1 with out a decimal and
it should pick up the first CAS.
I appreciate all your feedback, it not only helps make the product
better, it also helps others who read this understand how the product
works.
Thanks
Dave
SVC*HC>76536*255*57.41*0402*1~
<FIELD>PROCBILLEDAMT1</FIELD>
CAS*CO*45*161.39~
<FIELD>PROCADJCODE1.1</FIELD>
<FIELD>PROCADJAMT1.1</FIELD>
<FIELD>PROCADJCODE1.2</FIELD>
<FIELD>PROCADJAMT1.2</FIELD>
> procedure adjustments in the claim adjustment fields. MOAMIATYPE works great.
>
> I have attached a snippet of the X-12 Utility CSV file output.
>
> Thanks,
>
> Phil.
>
> P.S. When we get this right you might have a fluffy of X-12 utility sales.
> Certain hospital clients are looking to this application instead of using our
> services. They will still need the xml file to retrieve what they are looking
> for. Good for you and still good for us.
>
> ________________________________
>
> read more »
>
> snippet3.xls
> 75KViewDownload
Com1 Software
Regarding your point:
" I am expecting to only see inpatient claim adjustments in fields B
thru I, but I
am seeing both inpatient and outpatient adjustment data hitting in
those
columns"
After looking over your data I think I have a better understanding of
what you are getting at.
I am not sure but It sounds like your looking to filter some of the
data, like only show inpatient claims data?
In our X12 Parser ,we have an option available like filter=field,1234
where it will only export records that satisfy the filter.
Let me know.
Thanks
Dave
wrote:
Philip LaRochelle
I don't understand why I am seeing duplicate data in in CLMADJAMT1 and PROCADJAMT1.1. Especially when the record is an outpatient. It should be either in one or the other not both. Line 11 of the attached file shows column D11: CLMADJAMT1 = 161.39 and column Q11: PROCADJAMT1.1 = $ 161.39 Those dollars can not show up twice. This is not filtering option. Claim adjustments are different than Procedure adjustments. So the same numbers can not be in both. Either one or the other.
Inpatient records have claim adjustments as shown correctly in the snippet Outpatient records have procedure adjustments not duplicate data in both.
Thanks,
Phil