Payer Rules: Unit Billing

The Payer Rules tab allows users to create billing rules specific to each payer. This article is focused on Unit Billing rules. You must create or edit a payer rule to add a billing rule. Click here for more information on payer rules.

Adding a Billing Rule

Once you have created the payer rule, you can attach billing rules.

1. From an existing payer rule, click on the + Add Billing Rule button.
2. Select Unit Billing from the Billing Type drop-down.
3. Use the Codes field to enter the desired code or codes you wish to attach to the billing rule. The code(s) entered here will be used to match a service to this payer rule for the billing audit tool report.
4. Choose Duration or Quantity from the Conversion of Units By drop-down to set the manner in which units are defined.
• Selecting Duration will cause the rule to define units based on the duration of the service.
• Selecting Quantity will cause the rule to define units based on the number of services.

Duration

Duration-based rules define units based on time spent.

1. Use the Time Per One Unit (Minutes) field to define how much time equals a single unit.
1. If your unit of measure does not go evenly into the time of an appointment, it will round down to the nearest whole unit unless you check the Variable Time Unit Increment box.
2. Check the Variable Time Unit Increment box and add the Minimum Time to Round-up Units which determines the amount of time after which an additional unit is billed. For example, if your facility follows the Medicare 8-minute rule, you would enter 15 in the Time Per One Unit (Minutes) field and 8 in the Minimum Time to Round-Up Units (Minutes) field.
3. If you enter a value in the Maximum Allowed Units, a warning will appear on the billing report if the units on a billable item exceed the value entered here.
4. Select the Combine Services and Aggregate Units box to combine multiple occurrences of the exact same service into a single billing item.
5. Click Update to save the billing rule. 
6. You can add additional billing rules by clicking on the + Add Billing Rule again. To delete a billing rule, click on the red x next to the rule.

Quantity

Quantity-based rules to set units to the indicated quantity. You can use Replace or Calculate to determine the quantity billed.

Replace

1. Select Replace from the Method drop-down. This will automatically bill the same number of units each time the code is billed, regardless of time spent.
2. Set the Quantity field to the total number of units that should be billed for this code.
3. If you enter a value in the Maximum Allowed Units, a warning will appear on the billing report if the units on a billable item exceed the value entered here.
4. Select the Combine Services and Aggregate Units box to combine multiple occurrences of the exact same rule into a single billing item.
5. Click Update to save the billing rule. 
6. You can add additional billing rules by clicking on the + Add Billing Rule again. To delete a billing rule, click on the red x next to the rule.

Calculated

1. Select Calculate from the Method drop-down.
2. Use the Operator drop-down to select Multiply or Divide.
3. Enter the number you want to multiply or divide into the Conversion Factor field.  
1. Note: If dividing, this field will be called Conversion Denominator.
4. Enter the Maximum Allowed Units. This will place an error on the billing audit tool report if the number of units billed exceeds this number.
5. Select the Combine Services and Aggregate Units box to combine multiple occurrences of the exact same rule into a single billing item.
1. Note: If you are located in Arizona, the aggregation logic will also pull the second clinical rendering provider, if applicable, for the Box 19 requirement.
6. Click Update to save the billing rule. 
7. You can add additional billing rules by clicking on the + Add Billing Rule again. To delete a billing rule, click on the red x next to the rule.