Condition Expression

A condition expression defines what billing data qualifies a claim for a service type. Any data on a claim may qualify; you must use tokens to define that data.

Note: The Condition Expression functionality supports lookup tables containing ICD-10 ranges.

Tokens

A token is a term that describes the type of billing code to match on a claim. Tokens are used in service type definitions to:

  • Define the service type in the condition expression.
  • Determine resource reduction in the days or charges expression

The most common tokens and billing codes are listed below.

Token

Reference

Source or Field Locator

RevHas

Revenue codes

FL 42

ProcHas

ICD9, HCPCS, CPT4

FL 44, 80, 81

DRGHas

DRG codes

various

CDMHas

CDM codes

charge detail file sent to FinThrive

Operators

An operator is a term that links multiple tokens together in a single expression.The most common operators for condition expressions are listed below. For a complete list, refer to Online Help.

Operator

Function

Or

The service type will match if either of the codes is present

And

The service type will match only if both codes are present

And Not

The service type will match to the first code only if the following code is not present

Syntax Rules

The syntax in a condition expression must be precise. A misplaced space or bracket changes the meaning of the statement. Note the following rules when building a condition expression:

  • Use the appropriate order of operation, as in a mathematical formula.
    • Codes are linked by operators.
    • Codes in parentheses ( ) are interpreted as a single condition.
  • Include parentheses around:
    • Any token expression following an And Not operator
    • Any statement that returns a value (e.g. any < or > statements)
  • Insert a space:

Between the token, the code, and the operator:

Correct:

RevHas 450 And RevHas 420

Incorrect:

RevHas450AndRevHas420

When the expression references a lookup table:

  • Use open and closed brackets [ ] (instead of parentheses) around the table name.
  • A table name must exactly match the actual table name, including upper and lower case letters, spaces, etc.
  • The token must match the table type (i.e. If the table type is revenue codes, the token must be RevHas).
  • Do not insert a space before or after brackets [ ] referencing a lookup table.

Correct:

ProcHas [CCATH]

Incorrect:

ProcHas [ CCATH ]