Version 20.5
The Block and Substitute feature has been enhanced and renamed Advanced Workflow Rules Engine (or OP AWARE).
Click here to go to the OP AWARE Overview.
Version 20.4
Overview
Path: Billing tab > More button (Customize group) > Coding Substitution Rules
Block and Substitute Rules (or Coding Substitution Rules) can be created in OP to automate some of your common coding rules regarding CPT code modifiers, EPSDT codes, units, and ICD-10 diagnosis codes. There are three options to consider when creating these rules. You can substitute, add, or remove. Additionally, you can choose to apply a rule to all payers, or create rules one payer at a time. These rules will be applied to all superbills as they are posted and claims that are manually entered.
Field | Description |
Ins Payer Name | Select the payer that the rule will apply to, or select [*] to apply the rule to all payers. Rules may only be created for payers who have been marked 'Active for all' providers in the Insurance Payer List. |
Block Code | Enter the CPT code to block or search for it using the ellipsis button after clicking in the field. |
Subst Code | Enter the CPT code that will substitute the blocked code or search for it using the ellipsis button after clicking in the field. |
Mod 1, 2, 3, 4 | Enter the modifier to bill out with the CPT code or select it from the dropdown after clicking in the field (optional). |
EPSDT | Select if an EPSDT referral is required. Choose Y (yes) or N (no) from the dropdown after clicking in the field (optional). |
EPSDT 2 | Select if an additional follow up visit is required. Choose from the dropdown after clicking in the field (optional). |
Units | Enter unit count if it is different for this payer for this CPT code (optional). |
Date Activated | Select the date of service for the system to begin applying this rule. |
Expiry Date | Select the date for the system to no longer apply this rule. This is not necessary for new entries. |
ICD-9 | N/A - no longer used. |
ICD-10 | Enter the diagnosis code needed for billing this CPT code. If this diagnosis code was not listed in the encounter it will be added to the claim automatically. |
Operation | Choose from the following:
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Create an Add Rule
- Click the Add button
to add a new rule. A new entry line will appear. After the rule has been saved, it will be organized under the appropriate payer heading. - Choose an Insurance Payer or select [*] to apply the rule to all payers.
- Enter the Blocked Code.
- Enter the Substituted Code.
- Enter Mods 1-4 if necessary.
- Enter EPSDT and EPSDT 2 if necessary.
- Enter Units if necessary.
- Enter Date Activated. This is necessary in order for the rule to function.
- Enter the Expiry Date. This is not necessary for new rules.
- Enter the ICD-10 Code that should always be billed for the procedure to this payer.
- Select Add in the Operation field.
- Click the Save button
.
to add a new rule. A new entry line will appear. After the rule has been saved, it will be organized under the appropriate payer heading.
.Example: Your office bills all insurances for both the Flu A and Flu B test. The second test, according to your payers, should have a QW modifier. You want to create a rule so that your billers don't have to manually add the second test starting with today's claims.
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Create a Substitute Rule
- Click the Add button to add a new rule. A new entry line will appear. After the rule has been saved, it will be organized under the appropriate payer heading.
- Choose an Insurance Payer or select [*] to apply the rule to all payers.
- Enter the Blocked Code.
- Enter the Substituted Code.
- Enter Mods 1-4 if necessary.
- Enter EPSDT and EPSDT 2 if necessary.
- Enter Units if necessary.
- Enter Date Activated. This is necessary in order for the rule to function.
- Enter the Expiry Date. This is not necessary for new rules.
- Enter the ICD-10 Code that should always be billed for the procedure to this payer.
- Select Substitute in the Operation field.
- Click the Save button.
Example: Your office performs removal of impacted cerumen, CPT code 69210. Aetna has advised you that a -59 modifier is required for payment. You want to create a rule so that your billers don't have to manually add the modifier starting with today's claims.
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Create a Remove Rule
- Click the Add button to add a new rule. A new entry line will appear. After the rule has been saved, it will be organized under the appropriate payer heading.
- Choose an Insurance Payer or select [*] to apply the rule to all payers.
- Enter the Blocked Code.
- Enter the Substituted Code.
- Enter Mods 1-4 if necessary.
- Enter EPSDT and EPSDT 2 if necessary.
- Enter Units if necessary.
- Enter Date Activated. This is necessary in order for the rule to function.
- Enter the Expiry Date. This is not necessary for new rules.
- Enter the ICD-10 Code that should always be billed for the procedure to this payer.
- Select Remove in the Operation field.
- Click the Save button.
Example: Your providers often forget that 99000, specimen handling, is not reimbursed by any of your insurance payers. You want to create a rule so that this code is removed from all claim starting with today's claims.
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The above examples are for demonstration purposes only. It is important to keep in mind that all payers and states maintain different billing and coding guidelines.
