Add Patient Condition Codes

This rule is used to add a condition code to both institutional and professional claims.

Note: If you are requiring a condition code to be present or omitted on a corrected institutional claim, use this Claim Form Rule instead.

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. Then click Create Service Grouping Rule.
   
3. Select the Practice.
   
4. Then give the rule a name. As a best practice, we recommend using the affected payer(s) and the desired behavior to facilitate identification.
   
5. Adjust the order when applicable and select the service from the Service drop-down.
6. Select Conditions to create criteria that a claim should meet before the rule will apply.
   
7. Next, click Set Values, then click the box next to Condition Codes.
8. Input the code that should be applied to the claim.
9. To add more than one condition code, select Add Condition Code and repeat step 8.
10. Finally, click Save to complete the process.
    

Box Number

• UB-04: Box 18-28 - Condition Codes
• CMS-1500: Box 10d - Claim Codes

Frequently Asked Questions and Helpful Hints

Let's review some helpful hints and some more commonly asked questions!

Frequently Asked Questions

• The best way to determine if a scheduled change set is appropriate is to gauge how many claims will be affected. For example, if you want the rule to apply to previously billed claims as well as new claims going forward, create the rule without a scheduled change set. 
  
  However, if you want the rule to apply only to newly created claims, use a scheduled change set to instruct the system to look only for claims with dates of service on or after the set date. For more information on scheduled change sets, click here.
• If you are creating the rule to apply to previously billed claims, navigate to the Patient > Treatment Episode > Claims > Review Corrections section and click Check For Corrections. If corrections are generated, follow the process outlined here to complete the process. If no claims are flagged for rejection, click here to troubleshoot the rule why the rule may not be applying.

Helpful Hints

If one of your conditions is payer-based, select any applicable Current Sequence options 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.