Billing Audit Tool: Dynamic Billing Rule Examples

This feature is currently in limited release to a select group of clients and will be rolling out to everyone in the coming months.

The rules built here are meant to show the Dynamic Billing Rules feature in action and provide a general sense of some of the options available and the ways the different pieces can be used together. 

While the examples here can be used as baselines for your own dynamic billing rules, be sure that you have reviewed this article and understand the options available to you, as this list is neither exhaustive nor does it cover some of the more basic options.

Dynamic billing rules are highly customizable and should be tailored to match the specific needs of your facility and payers.

Required Permissions: You must be a Super Admin to create and edit billing rules.

For all of these rules, begin by navigating to the Billing Audit Tool tab and following the steps explained here to add billing details and add a billing rule.

Click on a header to expand the section and view the instructions.

Basic Examples

• Add Modifier rules will automatically assign modifiers for payers that require them based on the triggers chosen. In this example, we are going create a rule that automatically assigns modifiers based on place of service (but this trigger could be any one of the other available trigger types as well).

  1. To begin, add a trigger, and choose Place of Service as the trigger type. You must also choose the place of service match from the drop-down.
  2. Then click + Add Action, choose Add from the Action type drop-down, and Modifier from the Add Type drop-down.

  3. Type the modifier into the first modifier field. 

     

     • Once you've added a modifier to a field, the next modifier field will be editable. You can add up to four modifiers.
  4. Submit your changes. Now, any time a billing item has [21] Inpatient Hospital set as the Place of Service, the system will add 01 as the modifier. 

  If you add additional triggers, you can refine the rule further.

  • For example, you can add codes if you want to tie modifiers to specific codes. In this example, the modifier will be added to any items where Inpatient Hospital is set as the place of service AND the codes chosen in the rule trigger are present. 

    

  • Other common triggers for modifiers are duration and billing provider.
  • If you wanted the same triggers to perform another action in addition to adding a modifier, you can also add more actions. Just keep in mind that only items that meet all the entered trigger criteria will have the actions performed, and that every single action will be performed on those items.

• To add warnings or errors to a billing item, add the desired triggers (here we have chosen Codes). Then click + Add Action and choose Add and Warning/Error.

  

  • Then choose the desired condition for the Warning/Error Configuration field. You have the following options:

    • Require Service Auth: Choose this option to add an error message if a service authorization is missing from the billing item with the chosen trigger item(s) (in this case, codes).

      

    • Units Maximum: Choose this option to add a warning message if the units on the billing item exceed the value entered in the Maximum Allowed Units field (here, 2).

      

• In this example, we want to build a rule that will instruct the system to replace one code with another when a billing item has the matching code and claim format. 
  1. To begin, click + Add Trigger and choose Codes. Then type the code (or codes) you want to replace in the Codes Match field.
  2. Then click + Add Trigger again, choose Claim Format, then select the desired format from the drop-down.
  3. Next, click + Add Action, choose Replace as the Action Type and Codes as the Replace Type. Then enter the code (or codes) you would like to replace. Be sure to click Submit to save your rule.
  4. When this rule is active, the system will automatically replace the matching trigger code(s) with the replacement code(s) on billing items that have both the matching code and matching claim type.
•  You to create a unit billing rule, complete the following steps.
  1. To begin, select + Add Trigger, then choose Codes and enter the desired code(s).

  2. Then add the following Actions: 

     Replace: Choose Replace > Units, then choose Fixed or Calculation. Here we've chosen fixed. Bundle: Add a bundle and choose Custom > Daily to bundle billing items by day. Add: Then choose Add > Warning Error > Units Maximum to ensure that the billing item has a warning if the unit amount on the item exceeds the number entered.

• You can build Do Not Bill payer rules to elect codes that will automatically transmit billable items to the Do Not Bill tab. Once created, the report will run automatically at 5 AM ET, or when manually run by a user.

  1. Choose the triggers which will prompt the rule. In this case, we've chosen Codes and entered the matches. You can select one code or several. Then choose Remove > Billable Items for the Action.

     

  2. Next, click + Additional Properties.
  3. You have several options under Additional Properties, but here we're interested in Do Not Bill Reason. Select it and then click Submit.

  4. We now have the option to choose the Do Not Bill reason. 

     The Do not Bill Reason options are: Already Billed/Duplicate Paid Cash Non-billed Service Other

• If your facility has patients that are paying with private pay or other non-insurance based methods (such as scholarships, etc.), you can create rules to remove billable items for specific codes or other triggers. 
  1. To begin, make sure Non-Payers is selected as the payment type, and that a payment method is chosen. We are choosing Scholarship in this example.
  2. Choose the triggers which will prompt the rule. In this case, we've chosen Codes and entered the matches. You can select one code or several. Then choose Remove > Billable Items for the Action.
  3. If you need to, you can click + Additional Properties to add a Do Not Bill Reason field.

Advanced Examples

• If you want to build an admit-to-discharge rule, which will bundle all per-diem (in-patient, attendance based, or per diem service) charges for the patient's treatment episode into a single row in the billing report, you can start with a base like this.
  1. Choose the triggers which will prompt the rule. In this case, we've chosen Codes and entered the matches. You can select one code or several, and can bundle codes related to different levels of service, if needed. Then we selected Bundle > Custom > Admit to Discharge.  
  2. Next, click + Additional Properties.
  3. You have several options under Additional Properties, but here we're interested in Aggregate Units and Do Not Generate Until Discharge. Select them and click Submit

  4. In this example, we wanted both Aggregate Units and Do Not Generate Until Discharge. Check off the boxes.

     Aggregate Units: Checking this box will automatically add the units for each of the combined per-diem days (e.g., if you combine dates of service 8/1, 8/2, and 8/3, this would appear as a single row on the billing audit tool report with 3 units and a date of service as 8/1). Do Not Generate Until Discharge: If you check off this box, you will not see billable items associated with the code (or codes) entered until the patient is discharged. If it is not selected, then the codes will appear immediately.

• You can bundle codes to create a billing rule for MAT Dosing.

  1. Choose the triggers which will prompt the rule. In this case, we've chosen Codes and entered the matches. You can select one code or several. Then chose Bundle > MAT Dosing. Pick the desired billing period

     

     1. If you pick Weekly, you can choose which day starts the billing week, and the minimum number of days that can be bundled.
  2.  Then click + Additional Properties.
  3. You have several options under Additional Properties, but here we're interested in Window Bundle Code, Take Out Bundle Code, and Included Codes to Bundle. Select them and click Submit.

  4. You can now add codes 

     Window Bundle Code: This is the code that will be billed instead of the original code when at least one window dose is billed for the patient. Choose First Day of Billing Week (Dispense) or Last Day of Billing Week (Dispense) from the Date of Service drop-down depending on your facility and state requirements Take Out Bundle Code: This is the code that will be billed instead of the original code when at least one take out dose is billed for the patient during that week and no window dose was billed. You make the date of service the first day of billing week by dosage date or the first day of the billing week by dispense date. Included Codes to Bundle: You can add ancillary codes that will be included with this billing rule. When the system looks at these codes, it will look for the services matching these codes from the whole week.

• You can build Case Management rules to reduce the manual work needed to bundle case management so that billers don't need to manually calculate services rendered on a rolling 30-day period.
  • Choose the triggers which will prompt the rule. In this case, we've chosen Codes and entered the matches. You can select one code or several. Then choose Bundle > Custom. In this case, we've chosen Rolling Days for Billing Period and typed in 30 for Days to Bundle, though you can choose Daily, Weekly, Monthly, and Admit to Discharge as well.
  • Then click + Additional Properties.
  • You have several options under Additional Properties, but here we're interested in Minimum Service Set, Date of Service, and Through Date. Select them and click Submit.

  • We now have the options to choose the Date of Service, Through Date, and Minimum Service Set.

    Date of Service: Choose the Date of Service option from the drop-down.  First Day of Service: Choosing this option will set the bundle's date of service to the date of the first performed service in the bundle. Last Day of Service: Choosing this option will set the bundle's date of service to the date of the last performed service in the bundle. First Day of Month: Choosing this option will cause the bundled row's date of service to be the first day of the month that matches the latest date in the bundle. Last Day of Month: Choosing this option will cause the bundled row's date of service to be the last day of the month that matches the latest date in the bundle. The rule defaults to this option. Through Date: The selection here will dictate which of the options will be used as the end date for the bundle. First Day of Service: Choosing this option will set the bundle's through date to the date of the first performed service in the bundle. Last Day of Service: Choosing this option will set the bundle's through date to the date of the last performed service in the bundle. First Day of Month: Choosing this option will cause the bundled row's through date to be the first day of the month that matches the latest date in the bundle. Last Day of Month: Choosing this option will cause the bundled row's through date to be the last day of the month that matches the latest date in the bundle. The rule defaults to this option. Minimum Service Set: Click Add and then choose Minimum Service, Minimum Hour, or Minimum Unique Services from the drop-down. The bundle action will not apply until the bundle meets the required minimum set here. Direct services can be marked using the case_management_type in evaluation templates. For more information on field types like direct services, click here.