Within Payer Settings, Site Administrators have access to Diagnosis Code Rules, which help ensure claims meet payer-specific requirements and reduce the risk of denials.
Diagnosis Code Payer Rules:
Disallowed Diagnosis Codes: Diagnosis codes that are not accepted by the payer under any circumstance and should not appear on claims.
Disallowed Primary Diagnosis Codes: Diagnosis codes that cannot be used as the primary (first-listed) diagnosis on claims for this payer, though they may still be used as secondary diagnoses.
Disallowed Paired Diagnosis Codes: Specific combinations of diagnosis codes that cannot be submitted together on the same case.
Disallowed Paired Diagnosis + CPT Codes: Diagnosis code and CPT code combinations that are not allowed to be billed together on the same claim.
Accessing Diagnosis Code Rules:
Diagnosis Code Payer Rules can be configured at either the Payer level or the Profile level, depending on your needs.
Payer Level: Diagnosis Code Rules can be created for an individual payer.
To access these settings, navigate to Settings > Payers, then use the three-dot menu to the right of the desired payer. From there, open the payer settings and select the Diagnosis Codes tab.
Profile Level: Diagnosis Code Rules can be created for a Payer Profile to allow easy application of the same rule across multiple payers at one time.
To access these settings, navigate to Settings > Profile. Next, click the three dot menu to the right of the Payer Profile. Click Edit > Diagnosis Codes.