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<br />YES NO <br />[i] D RULE #14 - REPEAT PROCEDURES <br /> Whenever a physician bills for repeating a procedure within a <br /> specified period of time after the original procedure, it will <br /> deny. <br />[i] D RULE #15 - PROFESSIONAL COMPONENT <br /> When the physician is billing for the professional component of a <br /> procedure only, the corresponding technical component is reduced, <br /> so that the total does not exceed the maximum allowed for that <br /> procedure. <br />[!] D RULE #16 - RADIOLOGY UNBUNDLED <br /> Whenever more than one physician is billing for the same <br /> radiology episode, the physicians are paid according to the <br /> correct component of the radiology service. <br />GJ D RULE #17 - MUTUALLY EXCLUSIVE PROCEDURES <br /> Whenever a physician bills for "mutually exclusive" <br /> procedures (can not be performed during the same operative <br /> episode). The procedure of the highest value is paid, the <br /> remaining procedure( s) are denied. <br />[!] D RULE #18 - POST-OP CARE, RULE #19 - PRE-OP CARE <br /> Whenever a physician is billing for care before or after a <br /> procedure that another physician has performed, and if the <br /> care is within the global fee period of the procedure and for <br /> a related condition, it will be denied. <br />[!] D RULE #20 - MEDICAL PROTOCOL <br /> Whenever a physician bills for a procedure more frequently <br /> than is justified by the condition of the patient, it will pend <br /> for Utilization Review. <br />[!] D RULE #21 - FRAGMENTED PROCEDURES <br />Whenever a physician bills for multiple procedures on the same <br /> date of service (DOS) that are components of a major procedure for <br /> which there is a unique procedure code, the procedures are <br /> rebundled into the appropriate major procedure code. <br /> <br />3 <br /> <br />. ~ <br />rl-,Ni L <br /> <br />GROUP BENEFITS RISK POOL <br />