Creating Billing Rules to Combine Items

You can create billing rules to combine two items into one procedure code for an insurance carrier or plan. For example, you can create a billing rule to add the cost of a style addon to the cost of a progressive base lens and to display only the procedure code for the progressive base lens on insurance claims.

To create billing rules to combine items

  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, 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. In the Create Insurance Billing Rule window, select Combine Items from the drop-down list.

    The fields for setting up the billing rule are displayed.

  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. In the Select Item section, do the following:
    • From the Item Type drop-down list, select the first item type to combine.
    • From the Item Group or Item drop-down list, select the first item group or item to combine.
      • To apply the rule to all items in an item group, select an item group.
      • To apply the rule to only one item, select an individual item.
  10. In the 2nd Item section, do the following:
    • From the Item Type drop-down list, select the second item type to combine.
    • From the Item Group or Item drop-down list, select the second item group or item to combine.
      • To apply the rule to all items in an item group, select an item group.
      • To apply the rule to only one item, select an individual item.

  11. 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.

  12. 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.

    For Contact Lens item types only: If a carrier requires you to combine two contact lens items into one line item and then assign a special procedure code and modifiers to that line item, use this field to include the procedure code change in the Combine Items rule.

    • You must set up the Combine Items rule to combine item groups, not item names. For example, you could combine an item in the Disposable group with an item in the Cosmetic group into procedure code V2520.
    • You can use this field to change the procedure code for contact lens claims that initially have only one line item, such as a claim for one eye or for the same lens in both eyes, and therefore do not usually trigger the Combine Items rule.
    • You cannot create both a Change Procedure Code rule and a Combine Items rule for the same item group. If you have a Change Procedure Code rule for a contact lens item group, you must specify an end date for the rule before setting up a Combine Items rule for the same group. Otherwise, you will receive a conflicting rule error.
  13. Select modifiers from the Modifier 1, Modifier 2, Modifier 3, or Modifier 4 drop-down lists if necessary.
    To add codes to the drop-down lists, use the CPT Maintenance window in AcuityLogic Admin.
  14. From the Combine option drop-down list, select the option that best describes how to combine the selected items on claims:
    • Add total from 2nd item to 1st item and remove 2nd item from claim: Adds the cost of the second item to the cost of the first item and displays the selected procedure code and/or modifiers for the first item only.
    • Keep both Items on claim, apply Procedure Code and Modifiers to 1st Item: Displays the selected procedure code and/or modifiers for the first item, and displays the default procedure code set up for the second item.
  15. Click Save.

Related Topics