Creating Billing Rules to Combine Lens Components

You can create billing rules to combine all lens components—including base type, material, style, and color—by base type into one procedure code for a selected insurance carrier or plan. For example, you can create a billing rule to combine all the lens components selected for a bifocal lens into a single line item and to display only the default procedure code on insurance claims.

For multitenant environments, the following setup must be completed for each company. The parent company setup is not automatically applied to individual companies.

To create billing rules to combine lens components

  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. Enter the carrier name in the Carrier Name drop-down list.
  5. Enter the plan name in the Plan Name drop-down list if necessary. If you do not select a plan, the billing rule you create applies to all plans for the selected insurance carrier.
  6. Click Create.
  7. In the Create Insurance Billing Rule window, select Combine Lens Components from the drop-down list.

    The fields for setting up the billing rule are displayed.

  8. Enter an effective date range for the billing rule in the Start Date and End Date fields. If you do not enter a start date, the billing rule takes effect immediately. If you do not enter an end date, the billing rule remains in effect until you enter an end date.
  9. Select an item group or item you want the billing rule to apply to from the Item Group or Item drop-down lists. Select an item group if you want the billing rule to apply to all items in the item group, or select an individual item if you want the billing rule to apply to an item.
    This billing rule can be set up for lens base types only.

  10. 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.

  11. Select the procedure code you want to display on the insurance claim in the Procedure Code drop-down list. If you want the default procedure code to appear, select Use Procedure Code Mapping.
  12. Select modifiers from the Modifier 1, Modifier 2, Modifier 3, or Modifier 4 drop-down lists if necessary.
    The modifier codes available in the drop-down lists are set up in the CPT Maintenance window in AcuityLogic Admin if you need to add additional codes.
  13. Click Save.

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