Creating Custom Usage Rule in RM

mbpros · Post by **mbpros** » Wed Mar 02, 2016 5:43 am

One thing RM is not good at doing is validating Medicare LCDs to ensure valid dx codes are listed. For example, for chiropractic claims in some jurisdictions you must list a specific primary dx code...and you must list a secondary dx code that is on the list they provide in the LCD. Same thing with psychiatric claims where, for example, you must list one of 759 possible ICD10 codes to support medical necessity.

Because RM is not checking these dx codes the way it should, I would like to create a usage rule, but am not really sure how to do it. I do know the basics of creating usage rules and have created some already. But if I wanted to create a usage rule where, for example, the Primary Payer ID is 12502, I then would want to add a list of valid secondary dx codes (where Dx 2 must equal one of the codes on the list) and if the secondary dx code did not match, then an error would be returned. I'm not sure how to do it exactly...For example, if you select DiagnosisCode2, ICD10Code as the field and select Does Not Equal, would I have to do that 759 times for each Dx code in the LCD?

Steve

Post by **Gavin Walker** » Thu Mar 03, 2016 7:32 pm

Well, with 759 of them, that is going to be a massive rule. How are you going to keep up with the changes? You can quickly make a rule that Diag 2 is required for that particular payer.

mbpros · Post by **mbpros** » Fri Mar 04, 2016 3:10 am

I get notifications whenever there are changes to LCDs....so I don't mind the initial work of entering the dx codes...but am not sure how to do it.

Post by **Gavin Walker** » Sat Mar 05, 2016 12:46 am

I see what you mean. Unfortunately, there isn't a Common Edit rule that will test that the code is in a particular list.

mbpros · Post by **mbpros** » Sat Mar 05, 2016 3:55 am

Hey, Gavin, I realize there is no common edit rule. But what about creating a custom rule. I have done some custom rules that work fine. And even though one LCD has a list of 759 ICD 10s, another LCD only has 91 ICD 10s. So, for example, if I do a rule where Payer ID is 12502, then Diagnosis 2/ICD10 must equal M54.2 OR Diagnosis 2/ICD10 must equal M54.5, etc....I'm not sure how to do the OR clauses.