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<br />i~ NO <br />" 1:::::iUri'i:,!:1 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 />1:/:1 1:":::,:::,,,1 RULE #17 - MUTUALLY EXCLUSIVE PROCEDURES <br />Whenever a physician bills for "mutually exclusive" procedures (can not be <br />performed during the same operative episode). The procedure of the highest value <br />is paid, the remaining procedure(s) are denied. <br /> <br />1>-<1 ~':",I RULE #]8 - 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 />li~l( I,'",::il RULE #20 - MEDICAL PROTOCOL <br />Whenever a physician bills for a procedure more frequently than is justified by the <br />condition ofthe patient, it will pend for Utilization Review. <br /> <br />l!~~ 1.,::,::::,1 RULE #21 - FRAGMENTED PROCEDURES <br />Whenever a physician bills for multiple procedures on the same date of service <br />(DOS) that are components of a major procedure for which there is a unique <br />procedure code, the procedures are rebundled into the appropriate major <br />procedure code. <br /> <br />Il'l 1:;':'::,1 RULE #22 - SECONDARY PROCEDURE MANAGEMENT <br />Whenever a physician bills for multiple procedures, all of 'Yhich qualify for <br />payment, the procedure of highest value is paid in full. The remaining second <br />procedures are reduced to the specified amount allowed for that procedure, all <br />other procedures are denied. <br /> <br />~?01 Iii:!'::"::' I 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 />liL~':1 1,,::;,:,,:1 RULE #24 - UTILIZATION REVIEW <br />Whenever a physician bills for certain procedures that usually signify upcoding, <br />are of questionable appropriateness, or are inherently vague, and the patient's <br />condition does not warrant it, it will pend for Utilization Review. <br /> <br />J.0:'( li:ii!!:!:,:'::' RULE #25 - CASE MANAGEMENT <br />Whenever a targeted procedure or diagnosis is identified, the patient's records are <br />flagged for a special report which is available for review to determine the need for <br />case management. <br /> <br />" <br />