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What business rules apply when processing physician claims data?

April 26, 2017Business Data physician rules

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What business rules apply when processing physician claims data?

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1. If the HCPC is between 00100 and 01999 (Anesthesia) then the Line Service Count is set to 1. This corrects any potential mis-coding on the part of the carriers by substituting time units in place of the number of services. This applies to all years. 2. If the HCPC is between 95000-95199, 97110-97750, or 90780-97799 and the Line Service Count is > than 1, then the Line Service Count is set to 1. These codes have been identified as having been mis-coded in past years by the carriers. 3. If the HCPC is between 77419-77430 and the Line Service Count is 5′, then the Line Service count is set to 1. These codes have been identified as having been mis-coded in past years by the carriers. 4. If Line Allowed Charge Amount is equal to 0′ then the Line Service Count is set to 0.