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<br />DRAFT 6-6-01 <br />YES NO <br />~,';:::::::::I ~~I RULE #06 - ASSISTANT SURGERY <br />-:':"'''''';',-':,,', ,,,,,'-<':"""'."" Whenever assistant surgery is billed for a procedure that does not warrant <br />assistance, it will deny. <br /> <br />'1111:11'!11 1IIIIIIl RULE #07 - OBSTETRICAL GLOBAL FEE <br />Whenever office visits are billed by physician who also bills for the delivery <br />procedure code, and the visits are within the global fee period for the delivery, the <br />visits will deny, unless the visit is for a condition unrelated to the pregnancy. <br /> <br />_':"'yid 11'111'[[11 RULE #08 - SURGICAL GLOBAL FEE <br />Whenever a physician bills office visits, consults or hospital visits within the <br />global fee period for the surgical procedure, the visits will deny. There are <br />exceptions to this rule, for instance, a diagnostic procedure, as well as any visit <br />which is for a condition unrelated to the surgery. <br /> <br />~1::11:11illl P:II'1111il RULE #09 - NEW PATIENT CODE <br />Whenever a physician bills more than one new patient procedure code for the <br />same patient, it will deny, and insert a more appropriate visit code associated with <br />an established patient and allow payment accordingly. <br /> <br />riJ;lll~ l':ll:::al RULE #10 - INPATIENT IHM/DISCHARGE CODE <br />Whenever a 'physician bills more than one initial lHM code for the same patient <br />for the same hospitalization, it will deny. <br /> <br />ll:::!I!!,!~ 1!liililJ RULE #11- ICU VISITFREQUENCY <br />Whenever a physician bills more than a specified number of visits for the same <br />patient for the same date of service (DOS), the subsequent visit will pend for <br />Utilization Review. <br /> <br />_1111 111,1111 RULE #12 - IHM VISIT FREQUENCY <br />Whenever more than one physician bills for the same date of service (DOS) for <br />the same patient, and each is billing for a condition within the same "body <br />system", the later claims will be denied. <br /> <br />_';::f)f)!'!1 ll!i'lil RULE #13 - PHYSICIAN VISIT FREQUENCY <br />Whenever a ,physician bills for visits for the same patient for the same date of <br />service (DOS) (except leU), the visit of highest value is paid and the other visits <br />will deny. If the other visits are for different diagnoses, however, they will be <br />allowed. <br />