DOH Adjudication Guidelines

Factor for codes can be negotiated in the range of:

1-3

1.5-2.5

Level 1 to Level 4

Duration of Follow Up period.

One week calculated after the first day after the consultation.

7 Days including the day of the visit

7 Calendar days starting from the day after the visit

One week after a follow up consultation

Venipuncture code can be reported along with the lab services if the blood is drawn at the same facility/Encounter

True

False

When non-surgical management/cleansing of a wound is done, the following practice is correct:

Report 51-01,02,03 codes based on the area of the wound

Bill the correct code for Non surgical management and claim separately.

The service is unbundled and eligible for payment.

The services are included in the consultation and not separately identifiable

Services included in perdiem codes

Lab, Radiology excluding CT/MRI/PET and Physiotherapy

E&M Codes

Total cost of drugs exceeding AED1000

Single consumables exceeding AED1500

Histopathology and Special stain codes in the 8**** category are separately claimable in Perdiem codes

True

False

Code for Non surgical perdiem code for stay upto 7 hrs

25-02

24-01

25-01

Base rate for basic product DRG codes as per Mandatory tariff

8500

Factor 1

Variable and needs to be negotiated with the payer

15000

Definition of MUE

Maximum unit of services that can be reported for a patient/day

Maximum unit of services that can be reported for a patient Encounter

Maximum unit of Laboratory services that can be reported for a patient/day

MUEs can be bypassed if ordered by multiple specialists on the same day

False

True

A single encounter can be split and submitted as separate claims as per DOH

True

False

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