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<br />YES <br />IYl <br /> <br />~ <br /> <br />[J] <br /> <br />NO <br />II RULE #16 - RADIOLOGY UNBUNDLED <br />Whenever more than one physician is billing for the same radiology episode, the <br />physicians are paid according to the correct component ofthe radiology service. <br /> <br />I> I RULE #17 - MUTUALLY EXCLUSIVE PROCEDURES <br />Whenever a physician bills for "mutually exclusive" pTocedures (can not be <br />performed during the same operative episode). The pTocedure of the highest value <br />is paid, the remaining procedure(s) are denied. <br /> <br />1".1 RULE #18 - POST-OP CARE. RULE #19 - PRE-OP CARE <br />Whenever a physician is billing for care before or after a procedure that another <br />physician has performed, and if the care is within the global fee period of the <br />procedure and for a related condition, it will be denied. <br /> <br />II]] I., I RULE #20 - MEDICAL PROTOCOL <br />WheneveT a physician bills for a procedure more frequently than is justified by the <br />condition of the patient, it will pend for Utilization Review. <br /> <br />l1i.f 1..1 RULE #21 - FRAGMENTED PROCEDURES <br />Whenever a physician bills for multiple proceduTes on the same date of service <br />(DOS) that are components of a major procedure for which there is a unique <br />proceduTe code, the procedures are rebundled into the appropriate majoT <br />procedure code. <br /> <br />1rf.1 II RULE #22 - SECONDARY PROCEDURE MANAGEMENT <br />Whenever a physician bills fOT multiple procedures, all of which qualify for <br />payment, the procedure of highest value is paid in full. The Temaining second <br />procedures are reduced to the specified amount allowed fOT that procedllTe, all <br />other procedures are denied. <br /> <br />1.'1-1 1.1 RULE #23 - BILATERAL PROCEDURE MANAGEMENT <br />Whenever a physician bills for a bilateral procedure, the payment is reduced to not <br />exceed the maximum allowed for that procedure. <br /> <br />rn <br /> <br />D <br /> <br />RULE #24 - UTILIZATION REVIEW <br />Whenever a physician bills for certain procedures that usually signify upcoding, <br />aTe of questionable appropriateness, or are inherently vague, and the patient's <br />condition does not warrant it, it will pend fOT Utilization Review. <br /> <br />l.C:I:..1 1..1 RULE #25 - CASE MANAGEMENT <br />Whenever a targeted procedure or diagnosis is identified, the patient's records are <br />flagged fOT a special report which is available fOT review to determine the need for <br />case management. <br />