Set Up Clinical Edits

Clinical edits check to see if the dependencies between different codes (procedure, diagnosis, and so on) sent on a claim are met. Edits are made based on the required HIPAA Crosswalks. By default, all these edits are disabled. To enable clinical edits, you must set the variables that work with the corresponding crosswalk file to true. To enable the edits, in SpecBuilder:

  1. Open a guideline.
  2. In the right pane, click Rules tab.
  3. In the right pane, select User Global Declaration Script from the list of available scripts.
  4. Find the required variable and replace the value false with the value true.
  5. Save the script.

The following table lists the available variables:

Variable Description
ec_bHCPCSCoverage

Works with the HCPCS-Modifier crosswalk. The variable checks to see whether or not a specified HCPCS procedure code:

  • is covered,
  • requires the use of specific HCPCS modifier codes,
  • restricts the use of specific HCPCS modifier codes.
ec_bHCPCS_ICD10CM

Works with the HCPCS-ICD10CM crosswalk. The variable checks to see whether or not a specified HCPCS procedure code:

  • requires the use of specific ICD-10-CM diagnosis codes,
  • restricts the use of specific ICD-10-CM diagnosis codes.
ec_bHCPCS_Patient

Works with the HCPCS-Patient crosswalk. The variable checks to see whether a specified HCPCS procedure code is billed based on the specific requirements for patient's age (minimum/maximum) and gender.
ec_bICD10CM_Patient Works with the ICD10CM-Patient crosswalk. The variable checks to see whether a specified ICD-10-CM diagnosis code can be billed as a standalone code and whether it is billed based on the specific requirements for a patient's age (minimum/maximum) and gender.
ec_bHCPCS_POS Works with the HCPCS-POS crosswalk. The variable checks to see whether or not a specified HCPCS procedure code:
  • requires the use of specific Place of Service codes,
  • restricts the use of specific Place of Service codes.
ec_bHCPCSModifierCoverage Works with the HCPCSModifier-Coverage crosswalk. The variable checks to see whether or not a specified HCPCS modifier code is covered.
ec_bRevenue_HCPCS Works with the Revenue-HCPCS crosswalk. The variable checks to see whether a specified Revenue code:
  • requires the use of an HCPCS code,
  • requires the use of a specific HCPCS procedure and modifier codes,
  • restricts the use of a specific HCPCS procedure and modifier codes.

When an error is reported for rule violations, certain properties are added to the error object for reporting/analysis and acknowledgment creation. The values of these properties are picked up from crosswalk tables as follows:

  • EditCategory: used for severity adjustment, business grouping/reporting, and so on.
  • Custom codes for 277CA creation: From XEngine 8.8 and later, you can override standard status codes used to report errors in the STC segment with custom user codes.