Billing Generation Rules

(Topic Last Updated On: 04/26/2018)

Accounting > Third Party Billing (Advanced) > Billing Generation Rules

The Billing Generation Rules screen is accessible from the Third Party Billing (Advanced) sub-menu, under the Accounting menu. This screen is used to configure Phase type specific, variable Procedure Modifier values to be applied at the time of claim generation at the service line level. Configured Billing Generation values on this screen override the 'Proc. Modifier' values set on Billable Services with the same Payer, Service, and Service Type combination.

Field Descriptions

Billing Generation Rule Type

This field displays the rule type 'Phase-Modifier'. Currently this is the only available option.

Payer

This field contains a dropdown menu of Payer/Rate Groups. Payer/Rate Groups are configured using the 'Payer/Rate Groups' screen under the Accounting menu.

Service

This field contains a dropdown menu of all Billable Service options.

Service Type

This field contains a dropdown menu of Billable Service Types that are specifically associated with the selected Billable Service in the 'Service' field.

Position

This field has a up/down menu with the numbers 1-4. These represent the four Procedure Modifier positions (components SV101-3 - SV101-6) of the SV101 element in exported 837P EDI files.

Position Rule Type

This field contains two radio button options, 'Static Value' and 'Modifier Phase Rule'.

Static Position Value

This field is reserved for the user to enter a static Procedure Modifier value.

Phase

This field contains a dropdown menu of all system 'Phase Types'. Phase Types are configured using the 'Phase Types' Code table. Phase Types are associated on a per-patient basis, using the Dosing Information screen, found under the Pharmacy menu.

Value

This field is found in the 'Phase-Value Pairs' section. From this field the Phase Type specific Procedure Modifier values is entered.

Grid Columns

Payer Name

This column displays the selected Payer/Rate group from the 'Payer' field.

Service

This column displays the selected Billable Service from the 'Service' field.

Service Type

This column displays the selected Service Type from the 'Service Type' field.

Position

This column displays the selected Procedure Modifier Position (1-4) indicating where the modifier value will appear in the billing export service line.

Value

This column displays the user entered Procedure Modifier when the 'Static' position rule type is being used.

Command Buttons

New

Clicking this button allows for the creation of new Phase Modifier Rules.

Clone

After selecting a Phase Modifier Rule from the grid, clicking this button allows for the creation of a new Phase Modifier Rule using the selected records properties.

Edit

After selecting a Phase Modifier Rule from the grid, clicking this button allows for the rule properties to be changed.

Delete

After selecting a Phase Modifier Rule from the grid, clicking this button permanently deletes the record. This button also appears in the 'Phase-Value Pairs' properties section. After selecting a 'Phase-Value Pair', clicking this delete button removes the pair from the grid.

Add

This button appears in the 'Phase-Value Pairs' section of the 'Payer - Service Type - Position Details' properties. This feature is available when the 'Modifier Phase Rule' Position Rule Type is selected. After making a 'Phase' selection and entering in a 'Value', clicking this button will add that Phase and Value combination to the 'Pairs' grid.

Save

This button applies changes made when creating a new or editing an existing Phase Modifier Rule.

Cancel

This button will disregard any changes made when creating a new or editing an existing Phase Modifier Rule.

Clicking this button closes the Billing Generation Rules screen.

Procedures

How to Add a New Phase Modifier Rule
1.) Press the New button. 2.) Select the Payer/Rate Group from the 'Payer' dropdown menu. 3.) Select the Billable Service from the 'Service' dropdown menu. 4.) Select a corresponding Service Type from the 'Service Type' dropdown menu. 5.) Using the 'Position' up/down number menu, choose what position (1-4) the Procedure Modifier value will be placed in. 6.) Set a 'Position Rule Type' by choosing 'Static Value' or 'Modifier Phase Rule'. Static Value - This rule type makes the Procedure Modifier value a static, or constant, value. When using this rule type, the 'Static Position Value' textbox will become available. The Procedure Modifier value is entered into this field. Modifier Phase Rule - This rule type allows for the pairing of Procedure Modifier values with specific Phase types. When using this rule type, the 'Phase-Value Pairs' properties section becomes available. Patient Phase Types can be paired with Procedure Modifier code values using this section. a.) Choose the Phase Type from the 'Phase' dropdown menu. b.) Enter in the Procedure Modifier code value. c.) Click on the Add button to add the pair into the 'Phase-Value Pairs' grid. d.) Repeat steps a. - c. for each Phase Type. e.) To remove a Phase-Value pair from the grid. Select the pair from the grid and click the Delete button. 7.) Press the Save button.

How to Edit a Phase Modifier Rule
1.) Select the Phase Modifier Rule to be edited on the grid. 2.) Press the Edit button. 3.) Make the needed changes to the properties fields. 4.) Press the Save button.

How to Delete a Phase Modifier Rule
1.) Select the Phase Modifier Rule to be deleted on the grid. 2.) Press the Delete button to permanently delete the record. Note: Use the delete button with caution as there is no verification dialog box on this screen.

How to Clone a Phase Modifier Rule
1.) Select the Phase Modifier Rule to be copied from the grid. 2.) Press the Clone button. Using this feature will create a new Phase Modifier rule by copying the properties from the selected record. 3.) Make the needed changes to the properties fields. 4.) Press the Save button.

Considerations

One Active Rule Per Payer - Service Type - Position

The system only allows for one active rule per Payer, per Service Type, per Procedure Modifier position. A pop-up dialog box will appear when trying to save a Phase Modifier rule where a rule having the same Payer, Service Type, and Position already exists. The current active rule must be deleted before creating the new rule.