Free Redacted Document - District Court of Delaware - Delaware

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 1 of 83

EXHIBIT A

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 2 of 83

111111 11111111 UI 11111 11111 11111 liii 11111 lUll 11111 llll I·I·I

United States Patent
Holloway et a!.
[54] SYSTEM AND METHOD FOR DSTECTING FRAUDULENT MEDICAL ClAIMS VIA EXAMINATION OF SERVICE CODES

US005253164A

[ii]

Patent Number:

5,253,164
Oct. 12, 1993

[45] Date of Patent:

"Expert system identifies miscoded health claims",
Bests Review: Ljfe/Heoith. Nov. 1990, 60.

"Claims editing software runs coding rule checks",
Bests Review: Life/Health, Nov. 1990, 62. Woolsey, C. "Employer spots inflated medical bills",

(75] Inventors: Donald C. Holloway, Menlo Park,
Calif.; Robert D. Hertenstein, Morton, Ill.; George A. Goldberg, Newton; Kelli A. Dugan, South Natick, both of Mass.

Business Insurance, Jun. 25, 1990, 3.

Wcitzel, J. R. ci al "A Company/University joint venture to build a knowledge-based system", MIS Quarterly, vol. 12, No. 1, Mar. 1988, 23--34.

Assignee: HPR, Inc., Boston, Mass. [21] Appl. No.: 648,314
[73)

Leary, E. "SSA applies expertise to develop expert
systems". (Spotlight on Al--expert systems, Social Secu. rity Administration), Government Computer News, vol. 6, No. 17, Aug. 28, 1987, 49(3).

[22] Filed:

Jan, 29, 1991 Related U.S. Application Data

Beard, P. "Blue Cross develops insurance claim ES",
Al Week; vol. 6, No. 7, Apr. 1, 1989, 3.
puterworld, vol. 21, No. 50, Dcc. 14, 1987, 95,99.
No. 3, Autumn 1987, 22--4, 26--7, 30.

[63]

Continuation of Ser, No. 566,841, Aug. 14, 1990, aban.

Sullivan-Trainor, M. "Catching new clients", Coin.
Snyedcr, C. "From research to reality: the leading edge of expert systems", Insurance Software Rtview, vol. 12,

doned, which is a continuation of Ser. No. 252,307,
Sep. 30. 1988, abandoned.

[51] list, Q.'
[52] U.S. Cl [58] Field of Search
[56]

GO6F 15/21

364/406; 364/401 364/401, 406, 413.01 References Cited
....,.

U.S. PATENT DOCUMENTS
4,658,370 4/1987 Erman St al

2/1989 Hardy et a!. 4,858,121 8/1989 Barber et a!
4,803,641

364/513 .... 364/406

Christensen, J. "Insuring", High Technology Business, vol. 8, No. 10, Oct. 1988, 47--8. Expert Systems in the Insurance Industry: 1987 Survey Report Update, Coopers & Lybrand, 1987. Pallatto, J. "Expert system cures the blues". (Blue Cross develops insurance claims analysis system NERSys), PC 'Week, vol. 5, No. 50, Dec. 12. 1988, 35,44.

OTHER PUBLICATIONS 'Automated Claims Processing", Insurance Software Review, Marva J. Croaft Autumn 1988. pp. 52, 54. "Enhancing Accuracy and Timeliness Is Integral to the Claims Adjudication Process", Employee Benefit Plan Review, Anonymous, Dec. 1985 pp. l0.-12. "Heal thstar", Health Benefits Management System, Product Description, Version 1.Q24.
"System validates medical fee schedules", Bests Review: Ljfe/Healzh. Jun. 1987, 92.

Primary Examiner--Gail 0. Hayes Attorney, Agent, or FIrm--Wolf, Greenfleld & Sacks
[57]

ABSTRACT

An expert computer system for processing medical claims. Medical claims and associated representation are inputted into the expert computer system. The inpuüed claims are interpreted according to specific rules

and against a predetermined database to determine
whether the medical claims are appropriate,
16 Claims, 5 Drawing Sheets

MCK 000001

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 3 of 83

U.S. Patent

Oct. 12, 1993

Sheet 1 of 5

5,253,1O4

FIG. 1

FIGS 2
MCK 000002

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 4 of 83

U.S. .E-'atent

Oct. 12, 1993

Sheet 2 of 5

5,255,1ö4

FiG. .3

MCK 000003

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 5 of 83

U.S. Patent

oct. 12,

1993

Sheet 3 of 5

5,253,1tq

FIG. 4
MCK 000004

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 6 of 83

U.S. Patent

Oct. 12, 1993

Sheet 4 of 5

5,253,164

- /1.

.3.'

FIG. 5
/ RULES APPLIED TO
4'ULT/PLE CODE EITR/ES

8/ -81
El - El ·/ITEh'ACT

1/ -LI

7I, OS 08
2. RULES APPLIED TO
S/14'6'LE CODE El/TRIES

0/ 01

8T/TSELT

FIG. 6
MCK 000005

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 7 of 83

u.s. Patent

Oct. 12, 1993

Sheet 5 of 5

5,253,164

/1

FIG. 7
MCK 000006

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 8 of 83

1

5,253,164 2
Medicare resource based relative value scale

Medicaid fee schedules and Blue Shield relative Value scales for physician reimbursement in Massachusetts. s These approaches address only part of the problem: This application is a continuation of application Ser. establishing payment amount. A second, independent No. 07/56,84l, filed Aug. 14, 1990, now abandoned, which is a continuation of application Ser. No. component for. determining what physicians are paid is the code specifying the service provided. While true 07/252,307, filed Sep.30, 1988 now abandoned, coding errors on payment claims will always occur, 10 there also is evidence that somephysicians arc increasFIELD OF THE INVENTION
EXAMINATION OF SERVICE CODES

SYSTEM AND METhOD FOR DETECtiNG FRAUDULENT MEDICAL CLAIMS VIA

prices for different physician services; and revising

to

set

higher paying code than a procedure merits, or by Unpackaging services that were intended to bundled sion-making mechanisms for analyzing and applying into a single code. The administrative systems currently payments to such medical claims. 15 available are not adeqüáte to detect and correct most of these errors. BACKGRotj OF THE INVENTION
applied to the field of medical claims analysis and deci-

The present invention relates to expert systems as

ing their reimbursement by upcoding, assigning a

Standard industry practice allows medical claims To date, attempts to modify fee-for-service payment processors to enter the codes submitted on surgeon of physicians have focused only on price. Evidence is claims into a computer system. are applied accumulating that, while many errors are inadvertent, 20 to these codes establishing the Fee screensamount maximum that some physicians arc increasing their reimbursement by will be paid. Two coding methods most frequently used targeting the other component of the equation: codes are the American Medical Association's "Current Prodescribing the procedures performed. cedural Terminology, Fourth Edition (CPT-4)," and Declines in impatient care and physician visits over the "California Relative Value Studies (CRVS)." Sonic the last five years have been more than offset by the 25 claims administrators allow their claims processors to increase in prices of all providers. The net result has assign a code if it is absent from the claim; others return been an actual increase in the rate of real growth in the claim to the physician's office for a code, Once health care expenditures in the past decade because of entered into the claims processing systems, the code is lower general inflation. Cost cozjtajnmentefforts havtypically edited for consistency with the age and sex of ing so far concentrated on reducing unnecessary use, 30 the patient,, and sometimes for obvious rules in coding. now are beginning to address price. Additionally the After this step, if there is still a perceived problem with focus has been on hospitals more than physicians. Yet either the code or the fee, the claim is removed from the the cost of physician services, the second largest comproduction process and referred for review by clinical ponent of health care costs, was 20.1 percent of total staff. This reviewer, usually a nurse, may request the costs in 1986, up from 18.9 percent in 1980. Physician official operative report, of the costs climbed Il percent in 1986, compared with 7.7 35 surgeon's record, and/or call for a a required partreview hospital physician to percent for all medical costs and 1.5 percent for the the claim. A payment for the claim, if approved, is general economy. established, and the claim is returned to the processor In an effort to retain patients amid increased health for payment. Emphasis throughout the insurance induscare competition, physicians are negotiating agreements 40 try is on minimizing the time between when a claim is with managed care programs such as health maintereceived and when it is paid, rather than on its accunance organizations (lIMOs) and preferred provider racy. organizations (PPOs). Physicians give price concessions While the problems detailed above are generally to these organizations through a negotiated fee schedule accepted, the concern is whether the cost of obtaining or a discount from historic charges. In addition, they 45 the savings will warrant the effort. The solution, re agree to strong utilization controls to reduce unnecesquires that niedica1 judgment be applied to select the sary use. As a consequence, unless total patient volume most appropriate code(s) when subtle clinical distinc. increases, physicians have two primary options for tions result in significant differences in payment to the maintaining their income. One is to increase draznatimedical care providcr, or to decide when to request cally their charges to fee-for-service patients whose 50 additional information from the provider. However, beiiefit plans often pay the price that is customary in the applying the required expert medical judgment has he physician community. The other is to up their charges potential of slowing down the processing of claims and to managed care programs by the indirect method of significantly increasing the cost of doing so. At present, upcoding. processing of medical claims is done on an automated Incentives like these have driven the momentum in 55 basis using computer systems by relatively unskilled Washington, D.C. to reform the method of physician workers who input data, including the CPT-4 codes, payment for Medicare and Medicaid. While various into the computer and process them for payment. Usualternatives are being considered, such as capitation or ally, such an operator is unaware of whether the entity physician diagnosis related oups (DRGs), widespread to whom the request for payment is made, such as an implementation of such approaches is not imminent. 60 insurance company, should pay or not pay the claim as Instead, modifications to the fee-for-service, payment submitted. It is impractical for each of the operators to system are likely in the next several years. If such rehavea trained medical physician or technician to sit by forms can maintain satisfactory levels of patient access the operator and decide whether a particular claim while gaining physician support, a modified fee-for-ser. should be paid or not. The expense of such supervision vice method may remain the major payment method. 65 would result in costs which would offset any savings Thus far, attempts to alter fee-for-service payment realized by paying only the appropriate amount of the have included efforts such as: freezing Medicare physiclaim. Also, with a multiplicity of such medical reviewcian fees for specified periods; developing a model for a ers, inconsistent results would occur. Therefore, to save

MCK 000007

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 9 of 83

,253,164
expenses while maintaining productivity of the processing system, medical judgment must be incorporated in

4

required to assign appropriate codes to surgeon's 20
claims. CodeReview prompts the user for additional information not already entered into the computer, and will either recommend appropriate code(s) or recoin- mend pending the claims until additional information is

BRIEF DESCRIPTION OF THE DRAWINGS an automated data processing system which contains FIG, I is a block diagram of thc system of the present decision rules that can be used to automate the review Invent ion of claims being processed. S FIG. 2 is a flowchart of the overall operation of the In order to provide a cost effective automated data programmed computer of the present invention; processing system for achieving the desired results in FIG. 3 is a flowchart depicting the csnry program of paying only appropriately coded claim amounts, expert the programmed computer of the present invention; systems or artificial intelligence software provides the FIG. 4 is a flowchart of the operation of tile provehicle for widespread distribution of an expert's dcci- 10 grammed computer for multiple entries; sion-making guidance. An expert system in the form of FIG. 5 is a flowchart of the operation of the coma computer program is one which reasons like a human puter programmed for single code entries or multiple expert to solve the problems associated with appropricode entries which survive the flowchart of FIG. 4; ate coding of medical treatment for claims payments. FIG. 6 is a chart of the categories of rules applied to 15 the entries in the present invention. SUMMARY OF THE INVENTION FIG. 7 is a flowchart of the operation of the proCodeReview, a product of HPR, inc., the assignee of grammed computer depicting the lookup function of the present invention, uses expert systems techniques the computer programmed in accordance with the presespecially suited to representing the medical judgment ent invention.

DESCRIPTION OF THE PREFERRED EMBODIMENT Referring now to the drawings, there is shown in

FIG. 1 a general block diagram of a preferred embodireceived form the physician's office. The prompts and 25 ment of the present invention. Claims to be processed I recommendations provided by CodeReview are based. are received by the entity from whom payments are on the decision rules that physician reviewers have requested. A user designated at 3 enters various facts already used on a manual basis to solve identical probfrom the claims I into the computer system 2. Such facts lems and are consistent with informed surgical opinion. include, in addition to the entries for the one or more The present invention uses a Set of decision-making 30 medical procedures for which payment is sought, other rules coupled to a knowledge base of facts and observadata such as age of the patient, claim number, date(s) of tions to assist the medical claims processor. There is treatment(s) and procedure(s), the name of the physiincluded a knowledge base and a knowledge base intercian, etc. The computer system 2 may be any type of preter which applies the knowledge base using the rules suitable computer system which can interact with the specified in the knowledge base interpreter. The pro- 35 program of the present invention. One such suitable cess is an ongoing process which can be updated as new computer .system is the well-known IBM "personal methods of inappropriate coding are discovered. computer" containing sufficient data processing capaThe present invention utilizes the CPT.4 codes in the bilities and memory and suitable comxnerciafly available knowledge base of the expert system, although other database management software programs to perform coding methods for classification of medical procedures 40 the desired functions. Other suitable computer systems such as the CRVS discussed above may be utilized as esist and are intended to come within the scope of the well. The knowledge base interpreter is .a part of the present invention. The system may include a connection CodeReview program and contains an association of with another computer system 4 whereby the user 3, the CPT-4 codes with the knowledge base of expertafter having used the system and methods of the present derived decisions or rules. An example is the inclusion 45 invention, communicates his or her information to the of one CPT-4 code procedure within another CPT-4 computer 4 which approves payment for the claim code procedure. As a specific and simple example of the submitted. It is understood that the computer 4 could, in foregoing, a physician or his or her billing company appropriate circumstances, to be described below, remay submit a claim for payment for two procedures fuse any payment or be instructed to request further with appropriate CPT-4 codes for the procedures. If so information from the entity providing the claims 1. those two were CPT-4 numbers 49000 (or Exploration Generally, the user 3 will cuter into the computer of the Abdomen and 44140 for Partial Colectomy, and system 2 a description of the medical claims for which both procedures were performed on the same date, the reimbursement or payment is requested or the codes program of the present invention will recOmmend to the associated with such claims or both. The appropriate claims processor that code 49000 should only be paid 55 code(s) are then sent to the knowledge base interpreter when it is not done as part ofa code 44140 partial coin> 5 for its assessment of the coded claims. The interpreter toiny. Since code 44140 was performed, the claim for 5, using the rules of the present invention, interacts with code 49000 should not be accepted and paid. The comthe knowledge base 6 of the present invention and reputer program invokes a rule which has been specified turns .to the user 3 either a recommendation as to that states that if code 44140 appears with another code 60 code(s) for which payment is proper or requests the in .a particular range, which in this example includes user to provide further information or to obtain further 49000, the second code should be rejected and only the information from the entity providing the claim or refirst specified paid. The claims processor then rejects fers the claim to trained medical personnel for assessthe payment code 49000, authorizes payment for code ment. When the knowledge base interpreter has recom44140, and so informs the physician or billing company, 65 mended approval of payment of a particular type, the with the explanation given above. Without such a prouser 3 then may authorize payment to the provider of gram, the claims processor usually pays both code numthe processed claim or may forward that information bers. via input into computer system 4. A history database 7

MCK 000008

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 10 of 83

5,253,164 5 6 is provided to update and refine the knowledge base were derived using the CPT-4 classification system, and interpreter 5 and the knowledge base 6 and to monitor from various medical procedures which were examsavings assOciated with the recommendation. ined, classified, and possible combinations of proceReferring now to FIGS. 2 and 3, the user first runs dures assessed by expert medical specialists. From this the ENTRY PROGRAM shown generally at 7 in FIG. S effort resulted a series of rules which can be and are
3. Referring now to FIG. 3, in stepS, if the CPT-4 code

is given, the codes are entered into the programmed computer of the present invention and read at step 9. If

applied to multiple code entries (and single code entries

the codes are or may be incorrectly given, the
LOOKUP PROGRAM ID is run, as will be explained with reference to FIG. 7. If the entity which is requesting payment has provided a code entry or entries for the treatment given, then in step 9 it is detennined whether the code entry is valid or invalid by reference to the ALLCODE database 11. If an incorrect code (meaning here that there is no such alpha/numeric code or the code and description do not match) entry or entries are given or if no code entry is given at all, in step 9 the valid code entry or entries are specified by the process of the LOOKUP PROGRAM 10. By valid is meant that there is a code or codes for the treatment given a patient. It does not mean that the entry or entries are valid for payment. The ALLCODE database prefers. bly uses the CPT4 classification system, but other classification systems are intended to be within the scope of the present invention. The computer programmed in accordance with present invention then looks up in the SUPERSEDE database file 12 to determine whether an earlier code number has been superseded by another code entry in an updated version of the CPT-4 classification system. If the code(s) have been superseded, in step 13 the old code entry or entries are replaced by the superseded code(s) and this information is sent to the PROCESS database 17. In step 14, if another code was added in the preceding process, the program loops back to step 8 again. If not, it goes on to step 15. In step 15, any duplicaLe codes, if more than one code entry, are eliminated. However, in certain instances, duplicate codes are permitted, so that before eliminating the duplicate codes, a lookup in the database file 16 is per. formed to determine if the duplicate entries are valid. If there are no duplicate entries or or only one entry, step 15 is not performed. After step 15, the record tile, as

as well as will be discussedbejow). Each of the rules was developed as a result of reviewing medical procedures by expert medical personnel and is consistent with In the CPT-4 classification system. However, expert medi-

cal personnel also applied clinical judgment to situations where the CPT-4 classification system is not explicit or nonexistent. Therefore, for both single and
multiple code entries, a set of rules applicable to CPT-4 IS codes singleiy and in combination arc used to evaluate the appropriateness of the codes for payment. The operation of the rules is best illustrated by way of example with reference to the operation of MULTIPLE PROGRAM 21. In step 23, the codes, multiple in this case, 20 which have been read into a file in step 22 from PROCESS database 17, are examined first by looking up from INTERACT database 24 any references to those specific multiple codes presented in step 22 to which will be applied one or snore of the rules shown in sum25 mary form in FIG. 6 and more fully detailed in Appendix B. The first rules to be applied as shown in step 23, are rules referred to as El and E2 as shown in Appendix

B. These first rules are utilized for multiple records wherein one of the codes may be eliminated for pay. 30 osent approval purposes. Thus, in rule El, if one code number, here designated as ACODE, appears in the
same list of codes as one or more codes in the range of BCODE to CCODE, then ACODE is eliminated and

the code number appearing within the range of

sent to the PROCESS database 17. In step 38, the num- 45 bers from the CPT-4. In operation, when code numbers are entered into the computer programmed in accorber of codes resulting from the foregoing steps is dance with the present invention, the program will counted and stored. This count will determine whether perform a lookup of the code numbers ACODE and a particular program for multiple entries must be run, as XCODE. The INTERACT database 24 in the program will be discussed below. In step 19, the ENTRY PROGRAM 7 returns to the operations of the flowchart of 0 contains a reference that states Chat when ACODE is used with XCODE, and because XCODE is within the FIG. 2. bounds of BCODE to CCODE, only one code can It will be recalled that in step 18 the number of codes survive, in accordance with the El and El rules, By was determined and stored. In step 20, if the number of way of example, consider example I of Appendix A. codes determined was more than one, then the MULTIPLE PROGRAM is run in step 21, as wilt be presently 55 That example implements rule El. In example 1, code numbers 64450 and 10120 are entered in step 22 of FIG. explained. Referring now to FIG. 4, this figure is the 4. It is assumed that the date oftreatnient is the same for flowchart of MULTIPLE PROGRAM 21. In step 22, all code entries unless specified and entered otherwise. the multiple number of codes under consideration is If so, after a lookup in the INTERACr database 24, read out from PROCESS database 17. Generally, in the next series of steps, the program will examine the multi- 60 which contains information relating to the appearance together of 64450 and ]0120, the tatter appearing in a pIe codes presented to determine whether payment or range of codes analogqus to the.BCODE to CCODE payment authorization for each of the stated codes is example given above, by the El rule the program is medically appropriate, or whether one or more of the instructed to recommend elimination for 64450, with an codes is medically inappropriate, or whether one or all of the multiple codes should be replaced by other 65 explanation given if desired and as contained in such example 1. Of course, many examples of the operation code(s). of the El and El rules are possible depending on the In order to accomplish this, a set of rules developed codes which are analyzed. Two additional "E" rules for use of this program is now invoked. These rules

35 BCODE to CCODE is retained, It is this latter code number which will be further processed and perhaps approved for payment. Similarly, in the code E2, if code ACODE appears with another code in the range of BCODE to CCODE, ACODEis retained and the 40 code within the range of BCODE to CCODE deleted. By first applying rules designated as El and E2, it may be possible to eliminate one or more inappropriate codes from consideration. Of course, the codes are not ACODE, BCODE or CCODE but actual code nummay be affected by steps 9, 10, 13, and 14, is updated and

MCK 000009

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 11 of 83

These arc rules EP and EA. In rule EP, a code may be dealt with by the programmed computer, and thus must eliminated if the place of service is considered improper be referred to a human consultant. Rule QM states that or unpractical. An example of this rule EP is given as when ACODE appears with another code in the range example 17 of Appendix A. Rule EA is designed to 5 of ECODE to CCODE, there is a question about this eliminate a code where the age of the patient recomcombination of codes. The user 3 might be instructed to mends exclusion of one of the codes. An example of the review the claim and codes submitted, be asked to verapplication of this rule is given as example 18 of Appenify the dates(s) of treatment, or refer the matter to a dix A. Appendix A contains other examples of applicahuman expert. An example of the QM code being utition of the rules. 10 lized is set forth as example S of Appendix A. The code After step 23, the results are sent to update PROdesignated QS states that if code ACODE appears with CESS database 17. Then, in step 23', if there is oniy one another code in the range of BCODE to CCODE, then code number remaining after step 23, the program exits there is a question ibout ACODE. An example of this is to the RULES program of FIG. 5. This is because the given in example 6 in Appendix A. Finally, rule QB is "R" and the QM, QS and QB rules apply only to multi- IS applied to the codes presented. If ACODE appears with pie entries. After step 231, in steps 25 and 26, rules another code in the range of ECODE to CCODE, then designated as P.2 and RI are run, as will be explained there is a question about the code in the BCODE to below. The "R" rules of the present invention, as shown CCODE range. The foregoing example given would in Appendix B, generally replace the codes presented in apply to this code as well. step 22 with other code(s) not designated in the step 22. 20 After all three "Q" codes have been run on the codes Rule R2, for example, provides that if a code ACODE presented in step 28, having accessed the INTERACT appears with BCODE, both codes are deleted and redatabase 24, the next step 29 is implemented wherein the placed by CCODE. Rule R3 is sisilar to P.2 except that PROCESS database 17 is updated with the information more than two code entries are considered, here from the process of FIG. 4, and the program returned in ACODE, BCODE, and CCODE, which are replaced 25 step 30 to FIG. 2 and step 31. While rules Q, M, QS or by DCODE. Thus, the RI rule means replace one code QB may raise a question, about a code, it will not cause by another code; R.2 means replace two codes by aninterruption of the program, but will be reserved for other single code, and P.3 means replace three codes by later consideration by user 3. another single code. Other "R" codes could be develJust prior to implementing the portion of the prooped along the same line: RN would mean replacing N 30 grammed computer given as step 31, the programmed codes with one other code. As shown in FIG. 4, the computer up until this time has performed two operaRN-Ri rules are applied first before rule RI is applied tions, the first being the validation of the codes input by to the codes. Specific example of rules Ri and RI are user 3, and the second being the application of certain given in examples 2 and 3, respectively, in Appendix A. expert rules to multiple code entries. The resulting It must be understood that it is not required that each of 35 codes which will be presented to the portion of the steps 23, 25 and 26 will affect the code numbers proprogrammed computer in step 31 will either be a single ceased, but these steps are used if expert medical judgor a multiple (due to looping through step 21) code. ment indicates they are required to arrive at appropriate In step 31, the RULES PROGRAM represented by codes. the flowchart of FIG. is run. Referring now to FIG. Describing in greater detail the application of the Ri 40 , in step 32 the records of surviving codes are read out and RI rules, step 25 is first seen after having accessed from the PROCESS databate 17. If the code or one of INTERACT database 24. The results of application of the codes in step 33 is referenced in the BYITSELF the P.2 rule are sent to PROCESS database 17. Once database 34 as having a rule or rules applicable or relein step 25, the program queries from PROCESS again vant to it, in step 35 a series of "Q" rules is applied. It database 17 whether there remain multiple entries. If 45 must be appreciated that not all codes will be in the BYITSELF database, so that if there are three codes negative, the program is exited from as explained above. In step 26, rule RI is exercised and the INTERACT resulting from step 32, perhaps only one of those three database 24 consulted and compared. The result is sent will be in the BYITSELF file and will be subject to step to the PROCESS database 17. It is to be understood 35. If there are no matches with codes in the BYITthat the P.3 rule may be implemented for three codes. 50 SELF database, then the process moves dircctiy to step An example of the P.3 rule is given in Example 4 of 37. The purpose of the "Q" rules is to address an mdiAppendix A. In step 27, after consulting PROCESS vidual code which is one of the surviving codes after database 17 and determining whether a new code was the operation of the MULTIPLE PROGRAM or is the added in the application of the P.2 and the Ri rules and only code on thc claim for which payment is requested. the number of codes is greater than one, the program 55 The "Q" rules are rules to request more, information loops back to step 23 to exercise the application of rules about a particular code. For example, rule Qi states that P.2 and RI, E2 and El, EP and EA on the newly-resultif the code survived the set of rules applied to multiple ing (after step 26) codes. After step 27, in step 27' the codes under the MULTIPLE PROGRAM routine or is program queries whether the remaining codes exceed the only code submitted on the claim, then always a one code. If not, the program exits as explained above. 60 request for more information is made, as specified in the If, however, there remains more than one code resulting MESSAGE appended to the code. An example of the from the operations of, steps 23, 25 and 26, then the application of this rule is example 7 in Appendix A. In program enters a new ACTION PROGRAM to apply rule Q2, if certain fields have entries that match the rules QM, QS and QB, as shown in step 28. The "Q" set claim, more information is specified in MESSAGE. An of rules are designed to alert the user 3 that a problem 65 example of application of this rule is example 8 of Apexists in the context of the codes presented for payment pendix A. in rule Q3, if the code survives rules applied of that the particular syntax of the codes presented to to multiple codes or is the only code submitted on the the computer programmed in accordance with the presclaim, and the charge on the claim is greater than a

5,253,164 7 8 may be exercised over the INTERACT database 24. wit invention are such that they cannot be effectively

MCK 000010

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 12 of 83

sies" and refine, update and change the rules and the knowledge base interpreter 5. CODELIM, then the user 3 is directed to request more In steps 41 (End of File) and 42, the procesa of the information as specified in MESSAGE. AN example of computer programmed in accordance with the present this rule Q4 is example 10 in Appendix A. In rule Q5, if the code survives the rules applied to multiple codes or 10 invention is completed and the program exited from. At this point the user 3 has either confirmed that the is the only code submitted on the claim, and the.plsce of code(s) for which payment is requested are valid or service is P05, then the user 3 is directed to request have been modified to become valid or have been more information as specified in MESSAGE. In addipended so that more information may be obtained by tion, if CODELIM is not. equal to 0 and the place of of service is POS, the code in question is replaced by 15 the user 3 from the physician or his or her billing entity to aid in processing the claims. COPELIM and the message is flagged by MESReferring now to FIG. 7, the process of the SAGETYPE. An example of this rule is example II in LOCKUP portion 10 of the programmed computer will Appendix A. In rule Q6, if the code survives the rules applied to multiple codes or is the code submitted on the 20 now be explained. The purpose of the program 10 is to handle those situations in which claims cannot be read claim, and there is no evidence GE anesthetic as speciout, in step 9 of FIG. 3, from database 8. In step 43, the fled in ANESTHESM, then the user 3 is directed to user 3 inputè a description of the treatment noted on the request more information as specified in MESSAGE, claims form submitted by the physician or his or her An example of the application of this rule is example 12 billing entity. The LOCKUP Program 10 searches for a in Appendix A. Under rule Q7, if the code survives the 25 match in step 44 for the description given in step 43 rules applied to multiple codes or is the only code subfrom the index of theC]'T-4 manual in a database called mitted on the claim and the patient's age is between CPTINDX 45. The database 45 contains the records of BEGAGE and ENDAGE, then the userS is directed to the index, in machine-readable format, of the CPT-4 request more information as specified in MESSAGE: manual. If a match between input 43 and database 45 An example of rule Q7 is example 13 in Appendix A. In rule Q8, if the code survives the rules applied to multi- 30 does not occur, the process loops hack to step 43 for the user to reassess the description given and to give a new plc codes or is the only code submitted on the claim and description. If, however, a match is made, the program the diagnosis is DX, then the user 3 is directed to rewi]! display a number of related entries from quest more information as specified in MESSAGE. In addition, if CODELIM is not equal to 0 and the DX or 35 CPTINDX 45 the number of which may be selected by the programmer using well-known programming techICD9CODE is true, the code in question is replaced with CODELIM, and the reason for such action niques. The user 3 then chooses, in step 46, what he or she considers to be the most appropriate selection, flagged by MESSAGETYPE In all Q2 through Q9 which the LOCKUP program then searches for in step rules, the reasons sre flagged by MESSAGETYPE An example of the foregoing rule is given in example 14 in 40 47 in the CPT-4 code or other code shown as ALLCODE database 11. In step 48, the codes fetched from Appendix A. In rule Q9, if the code survives the rules the CODES database 49, a subset of ALLCODE dataapplied to multiple codes or code is only one submitted base II, sre displsyed with their descriptions. In step 50, on the form then ACODE is replaced wsth CODELIM the user 3 chooses one or more appropriste codes to and the reason is flagged by MESSAGETYpE. An example is example 15 in Appendix A. Another rule 45 match the description given in step 43 and the program updates the PROCESS database 17 with this informsknown as LI may be used and this rule relates to the tion in tep 51. Following such updating, in step 52, the amount of payment to be authorized to be paid. Rule LI program returns to step 9 as shown in FIG. 3. Of applies where the number of codes is greater than one. course, the process described with reference to .pro.. Rule LI is different from the other rules in that while gram ID may be performed with databases other than the other rules are generally concerned with the correct the CPT-4 example given. classification of authorization for payment, rule· Ll . There has been described above a programmed eomapplies to specific amounts. In rule LI, if ACODE spputer system and a method of progrnnming a computer pears with another code in the range of, and includes, system so that a knowledge base interpreter and a set of BCODE to CCODE, then the payment authorized rules may facilitate the classification and authorization limits the payment specified in ACODE to some amount DCODE. An example of the foregoing rule is 55 of payment to health care providers. Since the invention resides in a programmed computer of the antomatic given in example 16 in Appendix A. programming category, the development of this HISOnce the "Q° rules have been exercised in step 35, in TORY database 40 may lead to the development of new step 36 the PROCESS database 17 is once again upr'4es and a growth and refinement of the knowledge dated and in steps 37 (Eod of File), and 38, the step 31 of FIG. 2 completes running. At this juncture, the user 60 bsse interpreter 5. While the foregoing invention has been. described with reference to its preferred embodi3 views the recommendation screen for any relevant ments, variations and modifications will occur to those rules that have been applied, as discussed above. These skilled in the art. Such variatioth and modificatious are recommendations are generally a request for more inintended to fall within the scope of the appendedcJaims.
65

10 dollar sum given for that code as DOLLARLIM, then for-marion but may be something other than a request as the user 315 directed to request more information as in the case of a specific exclusion specified in a MESSAGE appended. An example of this message. In step 39 the PROCESS database 17 is appended to rule is example 9 in Appendix A. In rule Q4, if the code the HISTORY database 40 for recordkeeping survives rules applied to multiple codes or is the purposes code submitted on the claim, and the charge only 5 and for future use as a means to study these "case histoon the claim is greater then the fee screen for the code in

9

5,253,164

MCK 000011

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 13 of 83

11

5,253,] 64

12

''/'E
iple of "E1JE2 nile
!P.ica1

/

Sajcn with C1ije

User enters:

Pi.iiipt: Please enthrall CPr--4 pa± ccde8 aea.ring i claim, or, if a ' is alserit, look t1e Cc(8) prccedure nua1 or arther aid, arxi enter using t]e CPr--4 t c( s).
64450
101.20

t

,sr:
LWter

2. 10120 rve foreign bx±y

1. 64450 injti for rrve blcdc

re-start this aessjrz, ar enter all intxed c(s).

If all e are as ti If e or ixrè c re intxj, pra thxn. rct interI, pra Escape to

spse: Assign trw,e foreign x1y parxt; fol1rir (s) for 1. 10120
User

ess . enters (esses
OtErwise,

)ax ti reascm for t c1am(s),
key]:

a

Ftui.

uter1. 64450 is 1uth. hauae 64450 is I pase,
2. 10120 has been tai with r cthare.

tern

for lccal aTt1ja.

z4.i.ate to use

1
Exle of NR2 ]ile'picaa aicn with Ccx
_____
view

Please enter all T-4 prccaiure codes apieariiy t or, if a code is absent, look up ti'e cce(s) using tbe claim, CPT-4 puxure mazal or artber aid, ath enter tbe c( 5).

MCK 000012

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 14 of 83

er errters;
57250 58260

13

5,253,164
14

Xse: 1. 57250 rs.ir vagina ard

2. 58260 vagin.1 hys-teztay

If all cs axe as yci inteixied, press Itirn. If cr or e or re rt iiteixd,
iter esixae: Assign t1 follc*ing c(s) for pareiit:
press Escape.
key]:

press rart this sessjcg, aixi eiter all inteixt Escape to cx(B).

1. 58265 vaginal sterBtxiny xj Ib ]axw t] xscn f the char(s), press Itum.

flaj jAfr

er ters [presses

Catar

Jpznse: 1. In tinatic, s 57250 ar 58260 justify
y ox?ie 58265.

X'mp 3
pçal Session with Ccview. xxi1e of an "R.1 .le

PL

:

,

Please eit all CPT-4 prccuxe s searing on t claim,
prrcs±ize nua.i or axxit.her a.i.d, ard enter the e (a).
52281 52283

if a c is alsent, lk the co (s) using the CPr.-4

ters:

P'piiae: 1. 52281 cystcexçy & treat stricture

or re s e rt iritei1, pressIturn. Escape to xe--start this aesafr, ard enter all intexx .C(s).
If
Assign

2. 52283 cy5tceccpy & inject stricture If a.U axe as yi 1ntx!, press

1.

52283

the fol1ing cc(s) for payrxt:

2. 51600

injecti for b1+ir ay

cyetceccçy & inject stricture

MCK 000013

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 15 of 83

15

5,253,164 16

)o t .reaa for t1 charge(s), pEa tirn. Ot1rwise, prs
To

Escape.

er enters (presa
Cpster

key]:

Fsçr: 1. 52283 han
2.

52281 is reple by 51600, oauae all hit tha far cystcgraiy is iilted in e 52283.

with n change.

injti

__ of WR3e Exle
PiL

Thile

Typical

Sessi with Cèviaw

CaDiter : Please enter all T--4 prccedure ades açearing on t cla.im, or, if a c is alsent, 103k up the co ( a) using the T--4

er enters:93526
93543 93545

prure earnial or amther aid, ax enter the cc*ie(s).

Cater

pnise: 1. 93526 right arri left heart Catheterization 2. 93543 injtion for lart ays
3.

93545 injtji for coronary ays If all thiea are an y intxecI, press turn. If a or e codes re rct irrtd, pra Escape to re--start this session, arxl enter all int C(s).

pse:

Assign the fol]ing cc(s) for pat:
Otwise, press

1. 93549 left & right heart catheterizaU & arigrn Tb 1cx, the reaa for the charge(s), press 1thn.
key]:

ter enters (presses

er

x2se: 1. In 0z±iimaticn, cc 93526, 93543, sr 93545 justify
zep1xaxent by q:z 93549.

MCK 000014

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 16 of 83

17
--

5,253,164

18

--

Ele of NN
_____

ypica1 Ssicin with Ccx.Fview
-

PLAL

Please enter all r-4 xe±ire .cs arcearing ci t1 claim, or, if a is aeent, look the - (8) using the CPT-4
prccedure ñarn.3. or azx,t.her aid, ar enter the c (a).
58980 44000

er ters:

p1nse: 1. 58980 lapaxosccpy of relvis 2. 44000 tezolysis

te enters (presa cx keyp
?? 1. 58980 lapaxcecc of relvis ?? 2. 44000 enterolysis

bi

axe az 'i intx, press Ptuii. If ncze co were xt intex1ed, press Escape to re--ata.t this session, arxi enter all irxt _--(8).

If a.U.

Oe, press .Esce.
er enters (presses a key]:
______

Tb Jaw the xeasoo for the qesticin( 8), press 1ethrn.

laparnAccr, in which case zl-e kcth co with 5B985 If the prxes e tuafly sqsrate (wi]Jicaly), ]c5i

thm It is LUcely that lysis of sicrs urtu1 as part of the

heth co.

Exazple of r/" bi1e

Oiter

Pt : Please enter all CPT-4 ptccehire ccs açearing i the claim, or, if a is aheent, look i the ccx ( s) using the CPI'-.4
prccaiixe rnal or axther aid, arxl enter the ccxe ( a).

MCK 000015

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 17 of 83

er tez:
CQpiter

19

5,253,164 20

35820

33512

1. 35820 explore c1est vae]s far post-cp 2. 33512 x1ronazy arteries

Ihage

thj 855jc, er ters [esses e key]
ter

If all ccx are as yci inten'j, press Betuni. If or xre e rt inteix,

all irxterz c( a).

esa Escape to

?? 1. 35820 explore cst vse1e far Fx)et--op heicthage
2. 33512 ccnxrary arteries L'pazs

Otse, press Escae.· er ters (pzees key]:
pnse: Before acxtirxj
IVE:
BYz

'lb )orw tle rea.sai for t1 qtiai( a), press Beturn.

the cçertive rirt re a rjster nurse

35820:

rxivery x), jfl 4.jc1 case

to taanfre if the pet-cp b1eeisg cccusI thirix the z CreLJ.Ve aesaicx (hefore leaving the
rtpay for 35820.

--

12

Earp1e of Q1 ·

Thile

ypica].

Sessfrn with Cvi

_____

enter all CPT-4 prccere cxxs aearir on the cla.ini, or, if a e is &tsent, icok up the co(s) usir the T-4 prcciuxe rua]. or arot1- aid, ar enter the
58942

Please

pLse: 1. 58942 raiva1 of Ovary(ies)

MCK 000016

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 18 of 83

21

5,253,164

If s.11 cs are a ycu inta1,

Ftuxn. If cx or nrire .s .ere rxt interx1, prs E8cae to re-start this ses8icn, ar enter all irxtei-xJ

8

22

ter enters [pra a key]:
?? 1. 58942 rwval of ovary(i)

o(s).

er enters [presses

xeascn for Otxwise, press . tJe qiticri( a), pra turn.

]axw the

tu

key]:

________ ccrif.thn a diAgrceis

malinarxy, air 58940 as a rep1t.

or by reviBiirq t] ath]ogy repzrt. If tre is

of naiignarcy by ]sxkir at t1 claim,

r

-- 2.3

_____ L4lle of Q2' Thle

ypic&l Sessicai with Coie1vje,

Pruiit: Please enter all T-4 prccire cczs a.çea.rirq on ·te claim, or, if a is absent, lcrk up tbs Ccxié(s) uzir tbs i'--4·
ter enters:
________

prccture marnial or amitJr aid, ar enter tbs c(
38300

a).

1. 38300 drainage

of 1çh zx abscess; sinle

If or re s 're nt int, press Escape re--start this aesaicn, arzi enter al]. int

If all czcea are as i 1nt, press Pthrn.
key]:

r enters esses

to (a).

u1se: xter t1 tyke of arestbssia.

gil

A?'131&IA QtI:

MCK 000017

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 19 of 83

23

5,253,164

24

Local

Azèja tyce otr than thee 1iEt ave
ter ts [aft viig cursor to t1 cct line]: ]psez
Q3J1: Patit's age is 9 or ycinger Ptiazt's age is 10 or older

Arthesja type is rxt pzovii i tle c]Atm, or r evicrce of artJja is pov'i t tle claim

ti

t}e pstit's age.

.

er

(after m,vii cursor to t ct 1iz).:

P1 1z I? )21IA S AL

pxes Assign t1 foi1owx e(a) for payt:
Otlrwiae, press Escape.

A1 S 9 :

1. 38510 bicçsy or wciaic*i, deep cervical i(s)

krxi t] raai for t charx(a), prs tzxrn.

ter rters (pcesses Q key]:
________ 1. 38300 is changed to 38510 ause tha use of general

anest1ia dexcnstrates that this xire difficult than a staxxard, azteris3 38300 prxeIure; ar tha

child's age ilies that general anesthasia a

neaazy.
PA' 1W3:
ANY

ITICi OF RSFS ,S Cater 1xjse: Assign tha folld.ng (a) for paIt:
1. 38300 drainage of

rr*f aecesa; sinple TO )c tha xeasai for tha change(s), prees Iturn.
Othexwae, prees FcaE.
key]:

lii

l

er ters (preeses

criter

pEse: 1. 38300 has

xepte with r char.

MCK 000018

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 20 of 83

25

26

Exi1e of "Q3" mi

YPica1 Session with Crv-jew

Cater
P11.LL4It.

prccejure nma1 or an3thar aid, amL enter tF User enters;
38500

enter afl. T-4 prccedure cc aearing on t or, if a ce is a±eent, 103k t]E 03C( 8) using t} cl.a.tm, CPI'-4
Please

C( 8).

Cater

Psp3r; 1. 38500 bicçsy/ry'aj,

If

re--start this session, axxi enter all irrtax User enters [presses e key):

tuoi. If cz- or e c*xes ize nt intd, press Escape to

1iix*i rxie(s) ail ccxes are as yon intended, press

(s).

iprize: Entei t a trjata
Urr $300
$300 or
ND

claim for pzxxure 38500* charge as it açeara on thB

QIcE:

is lizta for 38500 User enters [a.fter nzving cursor to t2 ccu.t 1in]:
charge

PA E:

IS $300

?? 1. 38500 bicçisy/rarg,i, 1çEi
Otharwise, press User enters [presses key]:

Maign tha fo1kwii (a) for pay!uert:

b kzrw t]e racz for tha queet.icxi(s), prz Pebi.

r(8)

Ccpiter

Isxrse: Bfure

38500: VE: tha offire zrds revi BY:

: to determj tha extent of tha prxedure,

a registerai ixzse

103at in tha xxy. sir r1aat with any of · 38510--38525.

MCK 000019

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 21 of 83

PI : fl Cater

27

5,253,164

IS NT 1 ¶aAN $300:

28

Espse: Assign the fo1lcwLr C(s) for 1Ent: 1. 38500 bic. y/mrrval, lyki Ixde(s)

Otherse, press . er entersturn [presses key]:

Tb )cn the ress for the chex(i) ,

press

Itui.

er
_____

spinse: 1. 38500 has keen cta with rc change.

·Ex1e of Q4" le pica1 Session with CFvie,
Please

er enters:
·

prxehre marnial or arxDther aid, ar enter the c(
46934

or, if enter all CPr-4 proeiure cczsC(s) usii on the claJ.in, a _- is aheent, lcck up the a esriog the CPr-4

s).

1. 46934 destxtjciri of Im±ejds, interral

r enters [presses

rn

re-start this sessjczi, ax enter all inter1
key]:

If all s are as ycu intxed, press tui. If or re cs 're rct i.nte, press Escape to

(s).

Ipxez Please iiçaxe the charge on the claim for prore±lre 46934 with the parent limit for priure'46500 (injtii into

dcids):

1. rge for 46934 is

QTh

2. tharge for 46934 is LS 'flN U O 3. b charge is liat on the claim for 46934pyrt limit for 46500

'flW

pat limit for 46500

er enters [after raving cursor to the t lire]

Beth

P cNE OJ4 IS QELI ']3N PA LDT R 46500:
sez Assign the follcwing ox(5) for

?? 1. 46934 totion of IErthDjda, intl
/

t:

MCK 000020

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 22 of 83

5,253,164

To krEw t1 xeasa for .questicii(s), Otrwize,. za Fcare.

29

t

ess

30

er enters (za c key]:

ter 13 x hier pe:
payurt for

46500.

t tn t dn allb1e
465002

pI 'i: t' aii is r GzaR 'N pP IIT
c(s) for _______ Msign 1. 46934 strirticm of mr
Ueer enters (praes o key]:

t fo].1ir

pait: 3it]

To 3ai t1 reasi for tI chaxe ( s), pra Fthrn. Otherwise, pa EscaE.

cter pcirse:

· thm

1. 46934 has

en acceptai with x change.

//
c,1e of "Q5 Iile
Pi.ii4t
ypical

Ssi. with Cciiew

Citer : Please enter all T-4 pxtcedure
or,

(s) using t CP1'--4 pxccaluxe mam.iaJ. orartr aid, az erxte.r tha ccx5e(s).
93220

if a c is aent, lk up tha

açearir . tha claim,

User utters:.

Cxter pinse:

1.. 93220 vtczcaxd.thgran, with

interpretaticzi & xrt

If ail coe axe as yoi
er enters (presses cze key]:

re--start this sesaicEl, ai iter all inta c(a).

If cz or e cci xe rt intaI, press EscaPE to

intat, pra Iturn.

_

Ipxse; Thxter tha p1e of
Izçatient Ibspital
Oit

service for 93220.

vI QI:
MCK 000021

p. /ery t. /Suxg. Center

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 23 of 83

31

5,253,164

Ple of aervjc other than theelisted above Ple of serv is irt ptovid t claim

Of ffre

32

the ct 1ir]: P7ia Q: Th' PL½E F JIcE Is ATIr:
scse: Maign the foilcQing
5) for 1. 93222 vtoi, inte etatfrn & Iort crily Th )u, the reasczi for the chan(s), Otwise, prs -.

ter ters (after ixwing cursor to

pt:

er tar [pra
pzter

key]i

pj

I1se: 1. 93220 is chenj to 93222 baiise the heepital ra11y the se±vj.

r pt cp vi is oni
Otherwise, pEeB8 EBCape.

pro euipt a

Assign the foUisg (a) for pi1tz 1. 93220
Tb 1i the Zscn for the char (8),

with irxterpretatjcE & IWOrt

sa

Isixrise: 1. 93220 has teen ctaj with

ters thrn cr key]: (ses Cater
User

charge.

6mPLr1l --

21

xaip1e of 'Q6 Thle

ypical Ssicx with CedePevie1,

PiL: Please ter all T-4 crize codes açeerfrq on the claim, or, if a is aheent, lck up the code(s) uairg the a'r.-4
prccedure maI or airther aid, ar enter the c( 3).
User enters: 92502 90060

_______

2. 90060 visit, inteiiata, estab1is]i patient

1. 92502 ear-zrse-thxoat

with ra]. arthesja

MCK 000022

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 24 of 83

re--start this session, aixl ter all irrted de(s). ter enters [presses -- key]:

34 If all axe as yi 1ntexj, press If ci or e .ccc re rzt interded, press Esca.e to
-

33

5,253,164

rxre: &iter t1 tyre of arthasia liztal on tha claim.

Gal. 'ism, DIS:
Spisl

Anes-thaja type is rt provfrd on tha claim, or x. evidre

AzUja type other than t1e liatai ave
of arthaja.ja prov'icd on tha claim
line]:

ter enters [after vg cursor to t1
P)i z IF MD
IS LIS1)z

cP nIA PRWItD/MD TYPE CF .AZIA,

t

1. 90060 visit, ijitrndtate, estab1isi patient Jw t resacri for tha change(s), press !èthxn. Othae, press Escape. er enters [presses kay]:
·

Assign t foilcwing (8) for pasit:

________

1. 90060 has been sccepted with r change.

2. 92502 is ec1ixed: bcau9e t1re s x evire that

ra1 anesthesia a usei

P TSO: IF NY OI. BESE AiJT 12E'IHESIA 5 1lA;
the following crx(s) for parEnt: 1. 92502 ear-nse-thxoat exmn with general aithesja
Assign

2. 90060

visit, intmjjate, estab1is} tient
press

T

the reason for the change ()
kay):

Othex:wise, press Escape.

!ètxrn.

ter enters [presses

iinsi:

rer

1. 90060 has been acceptel ithr change. 2. 92502 has ken c,tai with r change.

MCK 000023

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 25 of 83

35

pifiL

13

36

Ex1e of NQ7 N

¶ypical Sessi-t with CczE.v'i1

Ccxter PiL : Please enter all CPT-4 prcce±xre c'xs açearizg t or, if a co is aleezxt, 1ok t o( s) usir ti claim, r-4 prtcsre ual or axØUEr aid, ar enter t cczie(s).

tI

ter enters:

54380

Qter1. 54380 r'pir penis for epispadias xjnse:
If all cs are as yi interd, press thrn.
re--start this sessicz, ard enter all intxi ccde(s). ter enters (presses

If Q or re es it irxterd, press Escapa to

cterEnter t patient's age. xxse:
Patient'a age is 17 or yQlxxJer

·

Ptient's age is 18 or olr P t2E: Th'

User enters (after zg cursor to t cut Uz]:
IS 18

pise: 1. 54380 repair penis forispadiaa ??
b krxNi t reaaai for t qticx( s), press Itui.

Oe, press Es.
er enters (pressea a

wter f.rr1j cept1rig code 54380: pxise:
for hypEp&iaz.

Za atys1cian tt rev.e Eli c.çtive
? IS 17

1fl at s really &z, ard a this really epispias? In a rxx-çeitatri.c patiit, t prccere is usually

pase:

1. 54380

zir eriis for epispailas
MCK 000024

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 26 of 83

37

D,2)3, 1b4

'lb kncw the reason for the Othezwise, resa Escape.

question(s), 8

38

ter enters [presses

ter 1nse:

key]:

1.

54380

has been sccepted with

ic change.

4mYL
_____ Kile of Q8 1ile pical Session with Cocrvie

_____ : Please enter all CPT--4 prtzèdu±e cc aearing on the c1im, or, if a is absent, look up the cce (s) usii the CPr--4
prxaure marsia.i. or arcther aid, ar enter the enters:
64782

(9).

cter 1. 64782 rwve rira, haixl or foot Resçcr:
re--start

rrve

If are yo.i If all sor asccx eintaxed, press 1turn. to cg e rct intand, press Escape

this session, sin. enter all intx1 (·s).

ter enters [presses cr key]:

sccnse:

t.he prc'vic3er'a sialty as it pears on the claim:

Poiiatrjst, 4, fcx,t tcir, foot gicup Specialty other than pediatrizt/Wfcct &ctcrJfrxt grtxip N provir specialty is liat on the claim ter enters [aftar nrix cursor to the ooect thE]:

P7i_r SPI_AZLr! QIcES

PZ Q: PRWI IS A I1iI5T:
CtYrriter

Pspxi: )ssign the follcwing

(a) for foot 1. 28080 x,e 2bxtcn' rèiraaa, pItt:

]oc the zsci for the char(s), press lètirn. Orwise, Escape.
ter enters [presses aE

MCK 000025

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 27 of 83

rii1ter xrise 3 A xir

39

5,253,164 48

cwter

if cziiningly lilcely to e a )trtcxi'e rrtQxly, rct as sh. flrefcxre, 64782 has i I)1aI
28080.

eisiczi çzfrirI ty a pxiiatrist is

PUQT IS NJI' A 1WThisr;

1rxxse: Assign t1e folkwing (e) for paytz

1. 64782 x hath or ft rve
T )w t} reasa for tha change(s), press }ebi.

Othaiwise, press .

ter ters (presses ore key]:

it2r1. 64782 has been axepta1 with rx change. sjxinse;
iple of "Q9" Rile
_____
Typical
-

Session with Cielvie

Ccter

or, if a

lease

enter all CPT--4 ptcs1uie ccx aearing on tha c].aiin,

er ters: 58605
Caipiter

preä're

is abeent, ink te c(s) using tha -4
or arxtier aid, aixl enter tha (s).

1srrinse: 1. 58605 dIvision of

fallopian be (paxtn airing a pjta1 I zation) If all e axe as you int, press Peturn.

re--start this session, art enter all irxtex n(s). er enters [presses cr key];

If cre or e orxs e rt int, press !scae to

Ppnse: Assign tha follcwing (s) for perent:
1. 58600 division o fallopian tube
press

)a tbe ou_,reason for tha change(s), press Ptui.

ter enters [presses

e.

Peti

key):

MCK 000026

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 28 of 83

41

5,253,164

Jsxnse: Ccz 58600 is U58 if fallopian b.te U.gatiai/tranzeticri te cly prooeôie perfrnr X·ii)g au RBiC1.

42

B

ca.l Ses8icxt with Cvie _____ Ei.zle of "Li" Rile
azzter

PL

: Please enter all C?T-4 prccelure xKes aesrir on t1e ci.aijn, or, if a ox is absent, look up the code(s) usir

ter enters:.

ptxedure zial or amt1r aid, ath enter t
43830
43840-

(5).

Ij: 1. 43830 strgica]. ing of .sth 2. 43840
reçair of s-tah lesion

ter

-

If all If

or .eare asrxt idta, press Escape to ee e yon int, press 1tu.

enter all irxti e(s).

lèsTzinse: Assign the fo1liing (s) for ps.rt: ?? 1. 43830 surgica]. cing of sth 2. 43840 repair of stnh leei
Otherwise, press Escape.

kixw the reason for the g.tion( a), press turn.
key]:

ter enters (presses

czise: 1. 43830 LImit paint of 43830 to $1.50,
with 43840.

ter

because

it aera

2. 43840 has l xta1 with z change.

/7

çle of "" ile ical Session with
Cater
Paji : Please enter aLl. CPT-4 prccshire c aearing on the claim, or, if a oo is absent, look up the c(s) using the T-4 preiuxe rEa1 or azxt.her aid, ar enter the oo(s).

MCK 000027

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 29 of 83

er ters:93005
93010

43

5,253,164 44

Ccnplt2r

Içcise: 1. 93005 electxccardiogrn, tziz only

2. 93010 electrocax1iogrm, interpretation & xort

If all e axe as yi iutez, pra

czly

xe--start this session, ai ter all intxI c(a). ter ters (presses a key]:
isçcrise: ter tI ple of sex:vice.

If ae or e ere zx,t mnten, press Ezcae to

Cter Pl of service otir tIn tse listai ae
Pl of service is rt provi on t claim
(after nEving cursor to t1 ct 1ii]:

Inpatit pital

Otpatimft rgy Office

P1i VI QIz

PA cIE IF PL v'I1 IS flT: cper
Fsrcnse: Assign t] follciwii
1.

______ 93010 electxtcardiograi, interpretation & 2xrt only.

(s) for payut:

t1 reason for t) chrige (s), press turn. Otrwise, press -.
'lb

ter ters [presses

key]:

spaise: 1. 93005 is e1: -aiiae t IcepitAl grafly pzvvjdes euift ar erfcc t service. 2. 93010

cwter

has k cspta with r change. 2. P Ti'O: IF PI1 IS O] DP.ATI2T:
1. 93000 e1eztxxazxLicgrain, crxx1ete

JI

Iexinse: Assign t foUdng code(s) for payunt: 'lb )aq tha reason for tj chaxe(s), press Retirn.
Ot1rwise, press Escaçe.

ter ters [presses

1y]:

ccrse: 1. In cinaticri, - 93005 ar 93010 justify
rep1iLent by code 93000.

MCK 000028

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 30 of 83

45

5,253,164

l/2L_ It
--8--

46

rle of "EA i1e

'Pypical Sessiai with Co1v±e

cxter:
P..LLLJL

Please enter all -4 ·prure cm t1 cl&m, or, if a is absent, 1k up taçearirxj tbs r-4 (s) using
prccs±xre nai-na1 or aixtbsr aid, ai enter tbs coce (a).
93503 93501

er enters:

ter

pcse: 1. 93503 right lEart cath; Sn-Ganz catheter
2. 93501 right

re--start this sass 1cm, arxi

If all If or .e or re rxit inteix, press Escape to

rtcatterizatiai; cmly are as yói int, press Feturn.

enter all int co( s).

(er enters [presses a key]:

ter the age of the patient. çse: ter
J 20 or *irr or o].r
Age 21

ter enters [after nving cursor to the t lii3:
PA! cE
Isp:xise:

CR !tX; Assign the folliing (s) far pazit: 1. 93503
IS 20

-

right 1srt cath; n--Ganz catheter

TO kz the reaacm for the change(s), press Fethrn.

Orwise, press

er enters [presses a y]
________ 1. 93503 has Ii acctaJ with z cha. 2. 93501 is elth 1-JmRe, in this age gzp, the b'

P T: ..

proce&zres are virtually it1a1.
IS 21
CR

________ Assign

1. 93503 right 1art cath; zn--nz cat1ter
2. 93501 right heart cathetazizaticm; cmly

the folldng x( a) for paxzt:

MCK 000029

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 31 of 83

47

48

Otiiwise,

1ax- tha reasal far t1 Chaige(8), presa Itui.
presa Escape.

er ellter3 (esse

Cater

pinse: 1. 93503 Iias cteI with r change. 2. 93501 ha ln accted with r change.

APPENDIX B
RULES DESCRIPTIONS

PART I.

Rules Applied to Multiple Codes: Contained in INTERACT.dbf

RULE

DESCRIPTION

Replace ACODE with DCODE
Ri

If ACODE appears with another code in the range of (and including) BCODE to CCODE, delete ACODE, keep BCODE to CCODE, and add DCODE. Replace ACODE, BCODE, CCODE, and DCODE (in ascending order) with ECODE

R2

If ACODE appears with ECODE, delete ACODE and BCODE and add CCODE.

R3

If ACODE appears with BCODE and CCODE, delete ACODE, BCODE, and CCODE, and add
DCODE.

R4

If ACODE appears with BCODE, CCODE, and DCODE, delete ACODE, BCODE, CCODE, and DCODE, and
add ECODE.

Exclude BCODE to CCODE (Keep ACODE)

E2

If ACODE appears with another code in the range of (and including) BCODE to CCODE, exclude BCODE to CCODE, and keep ACODE. Keep BCODE to CCODE (Exclude ACODE)

El

If ACODE appears with another code in the range of (and including) BCODE to CCODE, exclude ACODE, and keep DCODE to CCODE.

MCK 000030

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 32 of 83

Limit
Li

49

5,253,164

ACODE payment

50

If ACODE appears with anpther code in the range of (and including) BCODE to CCODE, limit the payment of ACODE to DCODE. If ACODE appears with another code in the range of (and including) BCODE to CCODE, and in POS ECODE, then exclude ACODE and keep BCODE to CCODE.

EP

is

EA

If ACODE appears with SCODE and if AGE is between CCODE to DCODE, then exclude ACODE and keep BCODE. Query for More Info because of Multiple Codes

QM

If ACODE appears with another code in the range of BCODE to DCODE, there is a question about this combination of codes. If ACODE appears with another code in the range of BCODE to CCODE, then there is a question about ACODE.
If ACODE appears with another code in the range of BCODE to CCODE, then there is a question about the code in the OCODE to CCODE range.

QS QB

IN ALL THE ABOVE CASES, IF THERE IS A SPECIFIC MESSAGE APPLIED TO THE RULE FOR WHICH CERTAIN CHANGES OCCUR, THEN THE MESSAGE NUMBER RESIDES IN ECODE, AND THE CORRESPONDING MESSAGE IS IN MESSAGE.dbf.
PART 11.

· Rules applied to each code individually: Contained in BYITSELF.dbf
RULE

DESCRIPTION If CODE survives rules applied to multiple codes or CODE is Only one submitted on the claim, then always request mor.e information ("by report) as specified in MESSAGE. If CODE survives rules applied to multiple codes or CODE is only one submitted on the form and more than one of the following fields have entries that match the claim: DOLLARLIM, CODELIM, POS, ANESTHESIA, BEGACE
to ENDAGE, DX,,

Qi

Q2

then request more information as specified in MESSAGE.
Q3

CODE survives rules applied to multiple codes or CODE is only one submitted on the form and the charge on the claim is greater than DOLLALIM, then request more.inforrnation as specified in MESSAGE.

If

MCK 000031

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 33 of 83

5,253,164

51

52

Q4

I.f CODE survives rules applied to multiple codes or CODE is only one submitted on the form and the charge on the claim is greater than the fee screen for CODELIM, then request more information as specified in MESSAGE.

Q5

If CODE survives rules applied to multiple codes or CODE is only one submitted on the form and the place of service is POS, then request more information as specified in MESSAGE. In addition, if CODELIM - 0 and the place of service
is POS,

replace the code in question with CODELIM and the reason is flagged by MESSAGETYPE.

Q6

If CODE survives rules applied to multiple codes or CODE is only one submitted on the form and there is no evidence of anesthetic as specified in ANESTHESIA, then request more information as specified in MESSAGE.

Q7

·

CODE is only one submitted on the form and the patients age is between BEGAGE and ENDAGE, then request more information as specifiedin
MESSAGE.

If CODE survives

rules applied to multiple codes or

08
·

If CODE survives rules applied to multiple codes or CODE is only one submitted on the form and the diagnosis is DX, then request more information as specified in MESSAGE. In addition, if CODELIM 0 and the DX, or ICD9CODE (or provider) is true, then replace the code in question with CODELIM, and the reason is flagged by MESSAGETYPE. If CODE survives the rules applied to multiple codes or CODE is only one submitted on the form, then replace ACODE with CODELIM, and the reason is flagged by MESSAGETYPE.

Q9

ALLCQC'E:

n4ormation wI?ich TTLE4

is the whit cnt&ins avery pertaina to certain COdes

4i1

3 wefl is

COOE = presented code (all codes r,presnP.)
description o4 code from CF'T--4
tape

.ZST

= rvj o4 code (reIatve v1ue unit? indicate i4 a lobal procedure (al)

inclusivi)

MCK 000032

Case 1:04-cv-01258-SLR

Document 424-2

Filed 06/22/2006

Page 34 of 83

5,253,164 53
SUPERSE:.
CODE

BEST AVAILABLE COPY

54

present-: code which is to be superseded

SUPERCODE

the code(s) which supersedes COOE"

INTERACT:
ACODE

-- contains CPT--4 codes

all rules

RULE --

El,

E2, R1--'l, ON, OS, OS, Li contains CPT--4 codes
all rules Pt, R3 +
LI
-

BCODE, CODE
DCODE --
DCODE

cpt4code

--

dollar

amount

ECODE

cpt4- code

R4

ECODE -- message ty;a

all rtas
except R4 and above

'lTRYDATE --

holds date rule was entered

INTERVIEW -- holds date rule was developed

BYITSELF:
·

CODE

code which presents