Add or Remove Condition Codes

This rule is used to require or omit condition codes from a claim.

Note: If you are adding a condition code to a new claim or adding a condition code to a professional claim, use this Service Grouping Rule instead.

Workflow

Let's review how to create a claim rule to add or remove condition codes on a claim!

1. Navigate to Management Center > Claim Rules.
2. Click Create Claim Form  Rule.
3. Select the Practice.
4. Next, give the rule a name.
5. Adjust the order as needed.
6. Update the Claim Type drop-down to Institutional.
7. Then select Conditions to create criteria a claim should meet before the rule will apply.
8. Next, click on the Behaviors drop-down.
9. Select Claim Condition Codes and click Add.
10. Update the dropdown to one of the following choices:
    1. Omit to create the claim without the Condition Code when present.
    2. Require and Write to Claim to always require the Condition Code to be written. 
    3. Write to Claim if Present to only include the Condition Code when that information is selected during the correction process.
       
11. To create multiple behaviors, repeat steps 7-9.
12. Finally, click Save to complete the process.

Box Number(s)

• UB-04:  Box 18-28 - Condition Codes
• CMS-1500: N/A

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.