Our question has to do with the SVC06 and additional modifiers. We have 4 or more modifiers submitted on the original claim. When we adjudicate, we add a modifier. Since only 4 modifiers can be sent in the SVC01 and SVC06, do we have to populate the SVC06 since the first four modifiers are the same since this would be against the situational rule, though there is a difference in the non-displayed modifiers? Or should we send three of the originally sent modifiers and the one we added so that the provider knows that we added a modifier (so that it is different from the submitted), and then the modifiers in the SVC01 and SVC06 do not match so the SVC06 can be sent?
The situational rule for the SVC06 states “Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send”. If the SVC01-03 through SVC01-06 only contains modifiers that were submitted, in either the SV101/SV201/SV301 or the NTE, then the SVC06 wouldn't be required and shouldn't be sent. If a payer added modifier is being sent back in the SVC01, though, then the SVC06 would be required to be sent.
In a future guide, the number of modifiers will be increased to 8 in both the 837 and 835.
When more than 4 modifiers were used for adjudication, payers should consider and report in the SVC01 (adjudicated data) the modifiers which were most relevant to process/pricing of the services. Payer added modifiers that don't impact adjudication but only are used for processing in the payer system wouldn't be returned.