Description
Use the Billing Code Rules page to view and configure CPT rules. Using these rules, the system will replace an order choice's CPT codes or charge codes with one or more new CPT codes or charge codes.
The system evaluates these rules when it generates outbound billing messages. If more than one rule qualifies for a specific order choice/billing host combination, the system considers the rules in alphabetic order of the description. This allows you to prioritize different rules defined for the same order choice.
Access
AdminCenter > Rules > Billing Code Rules
You must have the necessary security permissions to access the Billing Code Rules page.
Technical Manual
Viewing the Billing Code Rule List
The Billing Code Rule list page contains a list of up to 10 billing code rules. If the list is longer than one page, use the page links located below the list of rules to navigate through the list.
| Show active only | Select the checkbox to view only active billing code rules. You set the inactive/active status on the Billing Code Rule details page. See "Adding or Editing Billing Code Rule Details" below. |
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| Host | Select or begin typing in the search-as-you-type field to filter the billing code rules list by host. You set the rule's host on the Billing Code Rule details page. "See Adding or Editing Billing Code Rule Details" below. |
| Description | Select or begin typing in the search-as-you-type field to filter the billing code rules list by description. You set the rule's description on the Billing Code Rule details page. "See Adding or Editing Billing Code Rule Details" below. |
| Add | Select to open the Billing Code Rule details page, where you can configure a new billing code rule. See "Adding or Editing Billing Code Rule Details" below. |
| Refresh | Select to refresh the search results in the table list. |
| Billing Code Rule List Table | |
| Description | This column displays the description of the billing code rule. You set the rule's description on the Billing Code Rule details page. "See Adding or Editing Billing Code Rule Details" below. |
| Active | This column displays the inactive/active status. You set the inactive/active status on the Billing Code Rule details page. See "Adding or Editing Billing Code Rule Details" below. |
| Copy | Select the button to use the selected rule's configuration settings to create a new rule. |
Adding or Editing Billing Code Rule Details
| Active | Select the checkbox to designate the rule as active in the system. Clear the checkbox to set the status as inactive in the system. |
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| Description | Enter a description for the rule. This is a required field. |
| Host | Select in or begin typing in the field to search for and select a host to assign to the rule. |
Current Order Choice is in list
The section lists the order choices for which this rule will apply.
This will most commonly be used in conjunction with the Order contains all order choices including current order choice option to specify which CPT code to assign to an order choice when several order choices must be combined into one CPT code.
| Select Order Choices | Select this option to have the ability to select order choices without exceptions. |
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| All Order Choices Except... | Select this option to have the ability to select order choices with exceptions. |
| Order Choice | Enter text or select in this search-as-you-type field to add order choices. |
| Select | Clear this checkbox in the Select column to remove an order choice from the list. |
Order contains all order choices including current order choice
This section lists all order choices that must be on an order to trigger the CPT rule.
This option may be used in conjunction with the Current order choice is in list option to specify which CPT code to assign to an order choice when several order choices must be combined into one CPT code.
The program considers the order choice(s) you enter in the Current Order choice is in list section to be on this list.
| Order Choice | Enter or select in this search-as-you-type field to add order choices. |
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| Select | Clear this checkbox in the select column to remove an order choice from the list. |
Order Choice Frequency
This section allows you to set an occurrence range of different time increments.
| Condition Not Used | Select this option to designate that this condition is not used. |
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| Selected Order Choices | Select this option to determine the frequency for the selected order choices. |
| May not exceed ___ additional occurrences within ___ ___ of the current order's ___ | Enter values in the first and second available fields. Select Hours, Days, Calendar Days, Weeks, Years, Calendar Years, Calendar Months, or Fiscal Year from the first drop-down list. Select Order Date/Time or Collection Date/Time from the second drop-down list. Note This option displays when the Selected Order Choices option is selected. |
| Order Choice | Enter text or select in this search-as-you-type field to add order choices. |
| Select | Clear this checkbox in the Select column to remove an order choice from the list. |
Testing host is in list
This section lists where the testing must take place in order for this rule to be enforced.
| Host | Enter text or select in this search-as-you-type field to add hosts. |
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| Select | Clear this checkbox in the Select column to remove a host from the list. |
Diagnosis Code Condition
| Condition Not Used | Select this option to designate that this condition is not used. |
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| Selected Diagnosis Codes | Select this option to determine the diagnosis codes for the action. |
| All Diagnoses Except... | Select this option to determine the diagnosis codes to exclude for the action. |
| ICD-9 Diagnosis Code | Enter text in this field and select Search to search for a specific ICD-9 diagnosis code. Note This option displays when the Selected Diagnosis Codes or All Diagnoses Except... option is selected. |
| ICD-10 Diagnosis Code | Enter text in this field and select Search to search for a specific ICD-10 diagnosis code. Note This option displays when the Selected Diagnosis Codes or All Diagnoses Except... option is selected. |
Insurance Company Condition
| Condition Not Used | Select this option to designate that this condition is not used. |
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| Selected Insurance Companies | Select this option to determine the insurance companies for the action. |
| All Insurance Companies Except... | Select this option to determine the insurance companies to exclude for the action. |
| Insurance Company | Enter text or select in this search-as-you-type field to add insurance companies. Note This option displays when the Selected Insurance Companies or All Insurance Companies Except... option is selected. |
Insurance Type Condition
| Condition Not Used | Select this option to designate that this condition is not used. |
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| Selected Insurance Types | Select this option to determine the insurance types for the action. |
| All Insurance Types Except... | Select this option to determine the insurance types to exclude for the action. |
| Insurance Type | Enter text or select in this search-as-you-type field to add insurance types. Note This option displays when the Selected Insurance Types or All Insurance Types Except... option is selected. |
Patient Class
| Condition Not Used | Select this option to designate that this condition is not used. |
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| Selected Patient Classes | Select this option to determine the patient classes for the action. |
| All Patient Classes Except... | Select this option to determine the patient classes to exclude for the action. |
| Add | Select this button to open the Patient Class Search page, where you can add custom and/or system-supplied patient classes to the rule. Note This option displays when the Selected Patient Classes or All Patient Classes Except... option is selected. |
Test Condition
| Add Test Condition | Select this button to open the Edit Test Conditions CPT Rule page to add a test condition to the CPT rules. Once you've created and saved a test condition, a summary of the test condition will appear next to the Add Test Condition button. |
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CPT Code is in list
| Condition Not Used | Select this option to designate that this condition is not used. |
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| Any Selected CPT Codes | Select this option to determine CPT codes for the action. |
| All Selected CPT Codes | Select this option to determine the CPT codes for the action. |
| All CPT Codes Except... | Select this option to determine the CPT codes to exclude for the action. |
| CPT Codes | Enter text or select in this search-as-you-type field to add CPT codes. |
Charge Code is in List
| Condition Not Used | Select this option to designate that this condition is not used. |
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| Any Selected Charge Codes | Select this option to determine charge codes for the action. |
| All Selected Charge Codes | Select this option to determine the charge codes for the action. |
| All Selected Charge Codes Except... | Select this option to determine the charge codes to exclude for the action. |
| Charge Codes | Enter text or select in this search-as-you-type field to add charge codes. |
Date/Time Comparison
| Condition Not Used | Select this option to designate that this condition is not used. |
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| Any Date/Time Comparisons | Select this option to designate that at least one of the date/time comparisons defined must be met in order for the rule to fire. |
| All Date/Time Comparisons | Select this option to designate that every date/time comparison defined must be met in order for the rule to fire. |
| Add | Select the button to add a comparison to the list. |
| Proposed Collection Date/Time | Select to designate the condition to use the proposed collection date/time for the time comparison. |
| Approval Date/Time | Select to designate the condition to use the approval date/time for the time comparison. |
Plus Minus | Select Plus or Minus from the drop-down list. |
Days | Select Hours, Days, or Weeks from the drop-down list. Enter a value in the field to designate the number of hours, days, or weeks. |
X | Select the X button to remove the comparison from the list. |
Action to Perform
Replace order choice CPT codes with these codes
This section lists the CPT codes that you want to use when this rule is triggered to replace the CPT codes originally defined in the Order Choices page for the selected order choice(s).
If you do not select any CPT codes in this section, the program removes all CPT codes defined for the order choice(s) if this rule is triggered.
| Replace order choice CPT codes with these codes | Select this option to have the system replace any order choice CPT codes with the codes added. |
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| CPT | Enter text and select Search to search for CPT codes. Select the code to add it to the table, which displays the code and a description of the code. Select X to remove the code. |
| Append this modifier to the sample CPT codes ___ | Select this option to append the modifier, which should be added into the available field, to the sample CPT code. This action appends the selected CPT codes to a DFT message. |
| Not used | Select this option to specify that the CPT codes are not used. This is the default option when creating a new rule. |
Add CPT II codes
| CPT Codes | Enter text or select in this search-as-you-type field to search for and select CPT codes. Once selected, the codes appear in the table, which displays the code name, the description of the code, and active status. Clear the Select checkbox to remove the CPT code from the table. |
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Replace Charge codes with these codes
| Replace Charge codes with these codes | Select this option to have the system replace any charge codes with the codes added. |
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| Not used | Select this option to specify that the charge codes are not used. This is the default option when creating a new rule. |
| Replace Charge Codes | Enter text or select in this search-as-you-type field to select charge codes. Select the code to add it to the table, which displays the code and a description of the code. Clear the Select checkbox to remove the code from the table. |
Replace specific codes with a different code
Note
This CPT rule action is available only with an AP license.
| Replace specific codes with a different code | Select this option to have the system replace a specific CPT code with a different CPT code. You can select a specific CPT code to replace and select another CPT to replace it with. The second CPT code is not required and can be left blank to remove the first CPT code completely. |
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| CPT Code to be replaced | Select in or enter text in the search-as-you-type field to search for and select the CPT code you'd like to replace. |
| CPT Code to replace with | Select in or enter text in the search-as-you-type field to search for and select the CPT code you'd like to use to replace the CPT code you selected in the CPT Code to be replaced field (above). |
| Do not replace the first occurrence for the ___ | Select this checkbox to have the system make no changes to the first occurrence of the CPT code's entire order choice/case, part, or block while the subsequent occurrences of the CPT code on the order choice/case, part, or block will all be modified. Select one of the following options from the drop-down list:
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| Charge Code to be replaced | Select in or enter text in the search-as-you-type field to search for and select the charge code you'd like to replace. |
| Charge Code to replace with | Select in or enter text in the search-as-you-type field to search for and select the charge code you'd like to use to replace the charge code you selected in the Charge Code to be replaced field (above). |
| Do not replace the first occurrence for the ___ | Select this checkbox to have the system make no changes to the first occurrence of the charge code's entire order choice/case, part, or block while the subsequent occurrences of the charge code on the order choice/case, part, or block will all be modified. Select one of the following options from the drop-down list:
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| Not used | Select this option to specify that the CPT codes or charge codes are not used. This is the default option when creating a new rule. |
