Creating Billing Rules to Split Items

You can create billing rules to specify two procedure codes for one item for a selected insurance carrier or plan. For example, you can create a billing rule to split a progressive base lens into two line items with two different procedure codes 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 split 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. 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, elect Split Items 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 the item type to apply the billing rule to from the Item Type drop-down list.
  10. 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.

  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. Select the first 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.
  13. 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.
  14. Select the second procedure code you want to display on the insurance claim in the Procedure Code drop-down list.
  15. Select modifiers from the Modifier 1, Modifier 2, Modifier 3, or Modifier 4 drop-down lists if necessary.
  16. Select the option that best describes how you want charges to be split on claims between the selected procedure codes from the Split drop-down list:
    • Charge part of 1st Procedure Code and remainder to 2nd Procedure Code: Charges the amount you indicate for the item to the first procedure code, and charges the remaining cost of the item to the second procedure code.
    • Charge full amount to 1st Procedure Code and enter a specific amount for 2nd Procedure Code: Charges the full amount for the item to the first procedure code, and charges an additional amount you indicate to the second procedure code.
  17. If you selected the first option for splitting charges, perform one of the following procedures to indicate the amount you want charged to the first procedure code:
    • Select Fixed Amount from the drop-down list, and enter a dollar amount in the field. You can also enter a dollar amount for the Receivable.
    • Select Percentage from the drop-down list, and enter a percentage in the field. You can also enter a percentage for the Receivable.
    • Select Base Item Price from the first drop-down list, and select an item from the second drop-down list. The price set up for the item you select from the second drop-down list will be charged.
      The Base Item Price option is available only if you selected Lens Base Type from the Item Type drop-down list.
  18. If you selected the second option for splitting charges, enter the amount to charge the second procedure code and the receivable amount for the second procedure code.
  19. Click Save.

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