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<br />DRAFT 6-6-01 <br /> <br />Attachment B <br /> <br />HEALTHCHEX <br /> <br />Entity Name: City of San Marcos <br />Group #: <br /> <br />Effective Date: <br /> <br />Selections: <br /> <br />CODE DESCRIPTIONS AND FUNCTIONS: <br /> <br />YES NO <br />D D RULE #00 - CANNOT PROCESS <br />Whenever the claim does not have the minimum of information required by the <br />system to perform its auditing functions, the claim will need to be placed on hold <br />for review. <br /> <br />D D RULE #01 - OBSOLETE CODES <br />Whenever a procedure code is obsolete for the date of service (DOS) being billed, <br />it will deny. It will be replaced with the current/suggested code if one is available. <br /> <br />D D RULE #02 - EXPERIMENTAL PROCEDURES <br />Whenever a procedure code exclusively representing an experimental procedure <br />is billed, it will pend for Utilization Review. <br /> <br />D D RULE #03 - DISCRETIONARY/COSMETIC PROCEDURES <br />Whenever a procedure code considered to be cosmetic or discretionary is billed, it <br />will pend for Utilization Review unless medically qualified. <br /> <br />D D RULE #04 - APPROPRIATE USE OF MODIFIERS <br />Whenever a modifier is used with a procedure code which should not be used with <br />that particular modifier, the procedure will deny. <br /> <br />D D RULE#05-SEPARATEPROCEDURES <br />Whenever a separate procedure, or a procedure considered to be included in the <br />major procedure is billed, it will deny. <br />