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Payor837™ Edits List


Payor837™ is pre-loaded and maintained with industry standard edits/rules, including:

  • Procedure coding is checked for compliance with CCI policies, gender and age restrictions, inclusion of any required accompanying procedures, appropriate use of modifiers and medical necessity using CPT/ICD9 crosswalk data and LMRP.
  • Diagnosis coding is checked for use of valid primary diagnoses, proper levels of specificity, gender and age restrictions and the inclusion and ordering of any required accompanying diagnoses.
  • Situational/conditional data segments and elements are checked to see if they are required and reported. For example, if the diagnosis is an accident/injury diagnosis then an accident code and the accident date must also be reported.
  • Service/procedure related data segments and elements are checked to see if they are required and reported. These include fields related to ambulance, hospice care, chiropractic, home health, podiatry, durable medical equipment and other services.
  • Date fields are checked for consistency in relation to one another. For example, the date of onset/1st symptom must always be on or before the service date and on or after the patient’s birth date.
  • Data elements are checked for valid code sets and valid formats.
  • Proprietary Edits as determined by payor organization







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