The Rules tab allows customization to include or exclude modifiers, procedures and diagnoses for claim validation.
The Diagnosis screen can be accessed from multiple locations.
- Setup > Billing Setup> Diagnosis Codes
- Billing Portal > Setup Screens option on toolbar > Diagnosis
With the diagnosis code open, navigate to the Rules tab.
Code Validations
Providers - Select one of the following options:
- N/A (by Default)
- Rendering and Referring must be the same
- Rendering and Referring cannot be the same
The remaining validators can be utilized as needed by checking the associated box and entering the appropriate modifier, procedure or diagnosis.
- Check the box next to the Code Validation to begin setup
- Select the blue text to the right to add the appropriate qualifier (modifier, procedure, diagnosis)
When adding a modifier users will type in the modifier then select Update. Modifiers aren't searchable.
Procedure and Diagnosis codes are searchable by clicking the magnifying glass.
Company Settings
There are Company Settings that run claim validations for these Diagnosis Code Rules. These will need to be set to "Yes" in order to enable the setting within the Diagnosis Code setup and enable the diagnosis code rule validation on the claim.
- Check diagnosis rendering/referring provider - If checked, check claim diagnoses rendering/referring provider combination
- Check diagnosis required diagnoses - If checked, check claim diagnoses for required diagnoses
- Check diagnosis required modifiers - If checked, check claim diagnoses for required modifiers
- Check diagnosis required primary diagnoses - If checked, check claim diagnoses for required primary diagnoses
- Check diagnosis required procedures - If checked, check claim diagnoses for required procedures
- Check diagnosis restricted diagnoses - If checked, check claim diagnoses for restricted diagnoses
- Check diagnosis restricted modifiers - If checked, check claim diagnoses for restricted modifiers
- Check diagnosis restricted primary diagnoses - If checked, check claim diagnoses for restricted primary diagnoses
- Check diagnosis restricted procedures - If checked, check claim diagnoses for restricted procedures
