Add Patient Condition Codes

This rule is used to add a condition code to an institutional claim. 

Workflow

Let's review how to create a claim rule to add a condition code to a claim!

• 1. Navigate to Management Center > Claim Rules.
     
     
  2. Click Create Service Grouping Rule.
     
  3. Select the Practice.
     
  4. Next, give the rule a name.
     
  5. Select Conditions to create criteria a claim should meet before the rule will apply.
     
  6. Under Service, update the dropdown with the service you want the rule to apply to.
     
  7. Next, under Set Values, click Condition Codes.
  8. Input the condition code that should be applied to the claim.
     
  9. To add more than one condition code, select Add Condition Code.
     
  10. Click Save to complete the process.
       

Box Number

• UB-04: Box 18-28 - Condition Codes
• CMS-1500: n/a

Helpful Hints

• If one of your conditions is payer-based, select Current Sequence Behavioral instead of the Primary Behavioral Payer. This will ensure the rule applies to secondary and tertiary claims when needed. 
• To read more about how to set claim rule conditions and order, see the Claim Rule: Setting Claim Rule Conditions article.
• To read more about how to set up a claim rule to be effective as of a certain date, see the Scheduled Change Sets article.