Creating Billing Rules to Change Procedure Codes

You can create billing rules to do the following:

  • Change an item’s procedure code

  • Add modifiers for an insurance carrier or plan

For example, you can create a billing rule to change the procedure code for a progressive base lens to the procedure code for a bifocal lens on insurance claims.

To create billing rules to change procedure codes

  1. Open the Company Information window. See To open the Company Information window.
  2. Click the Insurance Rules link for your company.
  3. In the Insurance Rules window, select the Billing Rules tab.
  4. From the Carrier Name drop-down list, select the carrier to which the rule applies.
  5. If necessary, from the Plan Name drop-down list, select the plan to which the rule applies. If you do not select a plan, the rule applies to all the selected insurance carrier’s plans.
  6. Click Create.
  7. From the Billing Rule drop-down list in the Create Insurance Billing Rule window, select Change Procedure Code.

    The fields for setting up the rule appear.

  8. In the Start Date and End Date fields, enter an effective date range for the rule.

    • If you do not enter a start date, the rule takes effect immediately.

    • If you do not enter an end date, the rule remains in effect until you enter an end date.

  9. From the Item Type drop-down list, select the item type to which the rule applies.
  10. From the Item Group or Item drop-down lists, select an item group or item to which the rule applies.

    • Select an item group to apply the rule to all items in the group.

    • Select an individual item to apply the rule only to that item.

  11. If necessary, do one of the following:
    • If you selected Coating, Color/Coat Addon, Edging, Lens Base Type, Material Addon, Style Addon, or Tint from the Item Type list, select the eye to which the rule applies from the Eye drop-down list. Typically, you must do this only if you are applying modifiers or if a billing rule differs between eyes.

    • If you selected Frames from the Item Type drop-down list, enter the price range to which the rule applies in the Min Amount and Max Amount fields.

  12. Select an option from the Modifier Action drop-down list to set how the billing rule modifiers will be included on claims:

    • Append Modifiers - Adds the billing rule modifiers to the modifiers from POS.

    • Replace Modifiers - Replaces the modifiers from POS with the billing rule modifiers.

      • If a billing rule has a modifier, replaces POS modifiers with the billing rule modifier.

      • If a billing rule has no modifier, overwrites POS modifiers with a blank modifier value.

    • Do Not Change Modifiers - Leaves POS modifiers as is. Does not overwrite or append billing rule modifiers.

  13. From the Procedure Code drop-down list, select the procedure code to display on the insurance claim.

    To display the default procedure code, select Use Procedure Code Mapping.

  14. If necessary, select procedure code modifiers to add to claims from the Modifier 1, Modifier 2, Modifier 3, and Modifier 4 drop-down lists.
    To add codes to the modifier lists, use the CPT Maintenance window in AcuityLogic Admin.
  15. Click Save.

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