Payer Rules: Replace

If you need to replace billing codes for specific payers, you can use the Replace Code billing rule.

Required Permissions
You must be a Super Admin to add and edit payer and billing rules.

Creating a Billing Rule 

Before you begin, you must create a payer rule. For detailed instructions, click here. All fields marked with asterisks (*) are required and must be filled out.

1. Once you've created a payer rule, click Add Billing Rule.
2. Select Replace from the Billing Rule Type drop-down.
3. The rule will appear as follows.
4. You can replace codes, place of service, billing providers, and ancillary konnectors. 

Codes

The Trigger Type field defaults to Codes, and allows you to replace RCodes, HCodes, and CCodes.

RCodes

In order to replace RCodes, follow these instructions. All fields marked with asterisks (*) are required and must be filled out.

1. Click on the Codes field and either type in or scroll down to locate the desired RCode. Add a modifier if needed.
   • If the RCode you are replacing has an HCode associated with it and you want it removed, you can select the Rcode, select the same RCode in the Replacement RCode field, and then click the Drop HCode box.
   • If you do not select the Drop HCode checkbox, you will see the option to replace the HCode.
1. The Claim Format is set to Professional by default and the rule will appear as follows. Select the desired replacement code and add any necessary modifiers.
2. If the Claim Format is set to Institutional, the rule will appear as follows. Click on the Replacement RCode field and select the desired replacement RCode.
2. Once you have selected your code(s) and replacements, click Update.
3. You can click on the red x to delete the billing rule, or the up/down arrows to move the rule up or down in order if you have multiple billing rules.

CCodes

In order to replace CCodes, follow these instructions. All fields marked with asterisks (*) are required and must be filled out.

1. Click on the Codes field and either type in or scroll down to locate the desired CCode. Add a modifier if needed.
1. The default claim format is Institutional, and the rule will look like this. You must select a replacement RCode, and can also replace an HCode if needed.
2. If you choose the Professional claim format, the rule will appear as follows. Select the replacement CCode and add any necessary modifiers.
2. Once you have selected your code(s) and replacement, click Update.
3. You can click on the red x to delete the billing rule, or the up/down arrows to move the rule up or down in order if you have multiple billing rules.

HCodes

In order to replace HCodes, follow these instructions. All fields marked with asterisks (*) are required and must be filled out.

1. Click on the Trigger Codes field and type/choose the desired HCode.
2. Then select the HCode you are using to replace the original.
• If you choose Institutional for the Claim Format type, you can add an Rcode in addition to the required HCode and add modifiers as needed (Institutional is chosen by default).
• If you select Professional as the Claim Format type instead, the rule will appear as follows. Select the desired replacement CCode and add modifiers as needed.
3. Once you have selected your code(s) and replacement, click Update.
4. You can click on the red x to delete the billing rule, or the up/down arrows to move the rule up or down in order if you have multiple billing rules.

For more information on payer rules, check out the overview article!

Place of Service

• If you need to replace the place of service for specific codes, select Place of Service from the Trigger Type drop-down.
• Select/enter the code or codes for which you are changing the place of service.
• Then use the Replacement Place of Service drop-down to choose the new place of service.
• Click Update to save your changes.
• You can click on the red x to delete the billing rule, or the up/down arrows to move the rule up or down in order if you have multiple billing rules.

Billing Provider

• If you need to replace billing providers for specific codes, select Billing Provider from the Trigger Type drop-down.
• Select/enter the code or codes for which you are changing the billing provider.
• Choose the billing provider from the Replacement Billing Provider.
• Click Update to save your changes.
• You can click on the red x to delete the billing rule, or the up/down arrows to move the rule up or down in order if you have multiple billing rules.

Ancillary Konnector

• If you need to replace ancillary konnectors for specific codes, select Ancillary Konnector from the Trigger Type drop-down.
• Then enter the code or codes for which you are changing the ancillary konnector.
• Select the replacement konnector from the Replacement Ancillary Konnector drop-down.
• Click Update to save your changes.
• You can click on the red x to delete the billing rule, or the up/down arrows to move the rule up or down in order if you have multiple billing rules.

Type of Bill

• If you want to automatically tie the trigger code(s) to the type of bill entered in the Type of Bill field, select Type of Bill.
• Then enter the code or codes for which you are adding a type of bill.
• Enter the type of bill, which must be four characters or less.
• Click Update to save your changes.
• You can click on the red x to delete the billing rule, or the up/down arrows to move the rule up or down in order if you have multiple billing rules.