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<br />I:iJ <br /> <br />D RULE #16 - RADIOLOGY UNBUNDLED Whenever more than one physician <br />is billing for the same radiology episode, the physicians are paid according to the <br />correct component of the radiology service. <br /> <br />YES NO <br />I:iJD <br /> <br />[i] <br /> <br />[i] <br /> <br />[!] <br /> <br />[iJ <br /> <br />[iJ <br /> <br />[!] <br /> <br />D <br /> <br />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 />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 />D RULE #20 - MEDICAL PROTOCOL . <br />Whenever 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 />D <br /> <br />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 />D RULE #22 - SECONDARY PROCEDURE MANAGEMENT <br />Whenever a physician bills for multiple procedures, all of which 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 />D 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 />D <br /> <br />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 />