Sample Use Case

The following sample scenario shows you how to introduce a clinical edit that sends out an alert when a submitted Revenue code cannot be billed because the HCPCS code is not available in the data.

Note SpecBuilder 9.2 is used in this sample scenario.

After you have installed the product, complete the following steps:

  1. In SpecBuilder, on the Advanced tab of the ribbon, click Crosswalk Browser.

  2. On the left pane, click User, click HIPAA, click ClinicalEdits, and then select the Revenue-HCPCS crosswalk.
  3. Add the value 0637 to the source column RevenueCode, and then, add the value OCE-EDIT50 to the target column EditCategory and the value 1 to NeedHCPCS . You can also copy this row from the sample crosswalk file Revenue-HCPCS-OCE located at %ECRootPath%\STANDARDS\HIPAA\Crosswalks\ClinicalEdits\Samples\CMS_OCE.

  1. In SpecBuilder, click File, click New Guideline, navigate to the guideline EDI > HIPAA > V5010A > 837x223A2 > Health Care Claim: Institutional, Errata 2, and then click Finish.
  2. On the Rules tab, click User Global declaration Script and in the code uncomment the following line, and then save the guideline:

ec_bRevenue_HCPCS = true;

  1. Click the Analyzer/Data tab, and in the Data Wizard navigate to the sample data file located in the Edifecs Library at repository:/library/SampleScenarios/Clinical Edits Sample Scenario/837I-Claims-Edits.dat. Click Open, and then click Next.

  2. On the Data Errors tab, double-click an error to view the details.

The Revenue code that has been submitted in the element SV201 cannot be billed without the HCPCS code.