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<br />YES NO <br />I '/.;.1 lii,1 RULE #26 - ASSISTANT SURGERY UCR <br />Whenever assistant sUTgery is qualified for payment, payment is Teduced to not <br />exceed a specified amount allowed for that procedure. <br /> <br />1,,,,-1 I. ii.i I RULE #27 - CHEMISTRY LAB UNBUNDLED <br />Whenever a physician bills for more than one chemistry procedure code, they are <br />rebundled into the appropriate chemistry panel. <br /> <br />[II 1>1 RULE #28 - UCR/FEE SCHEDULE <br />WheneveT a physician bills for a procedure, payment is reduced to the maximum <br />allowed fOT that procedure. <br /> <br />liUl 1>1 RULE #29 - 31 - NO RULES CURRENTLY EXIST <br /> <br />I~ I EJ RULE #32 - NON-COVERED BENEFITS OR INVALID CODES <br />WheneveT a procedure code that represents a non-covered benefit is billed it will <br />deny. <br /> <br />I-\<l Ii il RULE #33 - MULTIPLE DISALLOWED PROCEDURES <br />Whenever a physician bills for proceduTeS beyond the frequency for which the <br />pToceduTe could possibly be performed, it will deny, (i.e. more than 1 <br />hysteTectomy). <br /> <br />[ill.J 1>1 RULE #34 - DUPLICATE PROCEDURES <br />Whenever a physician bills the same procedure code more than once for the same <br />patient on the same date of service (DOS) it will deny. <br /> <br />1'\.0:1 Iii RULE #35 - MANDATORY OUTPATIENT PROCEDURES <br />Whenever a physician bills fOT a pTocedure that is generally accepted as being <br />done only in an ambulatory setting, however is done on an inpatient basis, it is <br />flagged for investigation. <br /> <br />I~I liU I RULE #36 - POTENTIAL COORDINATION OF BENEFITS <br />Whenever a physician bills for a diagnosis that is representative of possible motor <br />vehicle accident origin or workers' compensation, it is flagged fOT review. <br /> <br />EEt1] Id RULE #37 - OFFICE VISIT UPCODING <br />WheneveT a physician bills for an extensive OT comprehensive office visit that is <br />in excess of the appropriate frequency for that diagnosis of the patient, it is <br />flagged for review. <br />