Custom Claim Validating Edit

CUSTOM CLAIM VALIDATION EDITS

This article will provide some common claim validation edits and how to enter them at the procedure code set up.  



97110 requires modifier GP when billed to Medicare

Fee Group Required based on Medicare Financial Class.

Setup > Procedure Codes > 97110 > Default > Modifier > GP

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Radiology Codes must have modifier TC – Medicare

Fee Group Required based on Financial Class.

Setup > Procedure Codes > [Enter Radiology Codes] > Defaults > Modifiers > TC

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New radiology codes must have modifier TC – Medicare

Fee Group Required based on Financial Class.

Setup > Procedure Codes > [Enter New Radiology Codes] > Defaults > Modifiers > TC

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J3260 - 1 unit equals 80 mg

Setup > Procedure Codes > J3260 > Fees:  Per Unit Fee, Units 1

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88305 to Medicare must be changed to G0416

Fee Group Required based on Medicare Financial Class.

Setup > Procedure Codes > 88305 > Billing > Billed As > G0416

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