We are currently updating the OP Help Center content for the release of OP 14.19 or "OP 19". OP 19 is a member of the certified OP 14 family of products (official version is 14.19.1), which you may see in your software (such as in Help > About) and in the Help Center tabs labeled 14.19. You may also notice that the version number in content and videos may not match the version of your software, and some procedural content may not match the workflow in your software. We appreciate your patience and understanding as we make these enhancements.

Block and Substitute Rules

Version 14.19

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: 
  • Substitute: Changes one CPT code to another or adds special properties to the selected CPT code as listed in the other columns.
  • Add: Allows a single CPT code to be converted into more than one service 
  • Remove: Blocks the CPT code but does not substitute with another CPT code. The blocked code will be ignored when it occurs for the specified payer and will not appear on claims.

Create an Add Rule

  1. 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.
  2. Choose an Insurance Payer or select [*] to apply the rule to all payers.
  3. Enter the Blocked Code.
  4. Enter the Substituted Code.
  5. Enter Mods 1-4 if necessary.
  6. Enter EPSDT and EPSDT 2 if necessary.
  7. Enter Units if necessary.
  8. Enter Date Activated. This is necessary in order for the rule to function. 
  9. Enter the Expiry Date. This is not necessary for new rules.
  10. Enter the ICD-10 Code that should always be billed for the procedure to this payer.
  11. Select Add in the Operation field.
  12. Click the Save button .
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.
  1. Select [*] in the Ins Payer field.
  2. Enter 87804 in the Block Code field.
  3. Enter 87804 in the Substitute Code field.
  4. Enter QW in the Mod 1 field.
  5. Enter Date Activated, today.
  6. Select Add in the Operation field.
  7. Save your new rule.

Create a Substitute Rule

  1. 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.
  2. Choose an Insurance Payer or select [*] to apply the rule to all payers.
  3. Enter the Blocked Code.
  4. Enter the Substituted Code.
  5. Enter Mods 1-4 if necessary.
  6. Enter EPSDT and EPSDT 2 if necessary.
  7. Enter Units if necessary.
  8. Enter Date Activated. This is necessary in order for the rule to function. 
  9. Enter the Expiry Date. This is not necessary for new rules.
  10. Enter the ICD-10 Code that should always be billed for the procedure to this payer.
  11. Select Substitute in the Operation field.
  12. 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.
  1. Select Aetna in the Ins Payer field.
  2. Enter 69210 in the Block Code field.
  3. Enter 69210 in the Substitute Code field.
  4. Enter 59 in the Mod 1 field.
  5. Enter Date Activated, today.
  6. Select Substitute in the Operation field.
  7. Save your new rule.

Create a Remove Rule

  1. 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.
  2. Choose an Insurance Payer or select [*] to apply the rule to all payers.
  3. Enter the Blocked Code.
  4. Enter the Substituted Code.
  5. Enter Mods 1-4 if necessary.
  6. Enter EPSDT and EPSDT 2 if necessary.
  7. Enter Units if necessary.
  8. Enter Date Activated. This is necessary in order for the rule to function. 
  9. Enter the Expiry Date. This is not necessary for new rules.
  10. Enter the ICD-10 Code that should always be billed for the procedure to this payer.
  11. Select Remove in the Operation field.
  12. 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.
  1. Select [*] in the Ins Payer field.
  2. Enter 99000 in the Block Code field.
  3. Enter 99000 in the Substitute Code field.
  4. Enter Date Activated, today.
  5. Select Remove in the Operation field.
  6. Save your new rule.

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. 

Version 14.10

Overview

Utilities Menu > Manage Practice >  Blocked & Substituted Rules

Block and Substitute Rules can be created in OP 14 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: 
  • Substitute: Changes one CPT code to another or adds special properties to the selected CPT code as listed in the other columns.
  • Add: Allows a single CPT code to be converted into more than one service 
  • Remove: Blocks the CPT code but does not substitute with another CPT code. The blocked code will be ignored when it occurs for the specified payer and will not appear on claims.

Create an Add Rule

  1. Click the Add Rule 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.
  2. Choose an Insurance Payer or select [*} to apply the rule to all payers.
  3. Enter the Blocked Code.
  4. Enter the Substituted Code.
  5. Enter Mods 1-4 if necessary.
  6. Enter EPSDT and EPSDT 2 if necessary.
  7. Enter Units if necessary.
  8. Enter Date Activated. This is necessary in order for the rule to function. 
  9. Enter the Expiry Date. This is not necessary for new rules.
  10. Enter the ICD-10 Code that should always be billed for the procedure to this payer.
  11. Select Add in the Operation field.
  12. Click the  Post Edit button to save.
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.
  1. Select [*] in the Ins Payer field.
  2. Enter 87804 in the Block Code field.
  3. Enter 87804 in the Substitute Code field.
  4. Enter QW in the Mod 1 field.
  5. Enter Date Activated, today.
  6. Select Add in the Operation field.
  7. Save your new rule.

Create a Substitute Rule

  1. Click the Add Rule 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.
  2. Choose an Insurance Payer or select [*} to apply the rule to all payers.
  3. Enter the Blocked Code.
  4. Enter the Substituted Code.
  5. Enter Mods 1-4 if necessary.
  6. Enter EPSDT and EPSDT 2 if necessary.
  7. Enter Units if necessary.
  8. Enter Date Activated. This is necessary in order for the rule to function. 
  9. Enter the Expiry Date. This is not necessary for new rules.
  10. Enter the ICD-10 Code that should always be billed for the procedure to this payer.
  11. Select Substitute in the Operation field.
  12. Click the  Post Edit button to save.
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.
  1. Select Aetna in the Ins Payer field.
  2. Enter 69210 in the Block Code field.
  3. Enter 69210 in the Substitute Code field.
  4. Enter 59 in the Mod 1 field.
  5. Enter Date Activated, today.
  6. Select Substitute in the Operation field.
  7. Save your new rule.

Create a Remove Rule

  1. Click the Add Rule 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.
  2. Choose an Insurance Payer or select [*} to apply the rule to all payers.
  3. Enter the Blocked Code.
  4. Enter the Substituted Code.
  5. Enter Mods 1-4 if necessary.
  6. Enter EPSDT and EPSDT 2 if necessary.
  7. Enter Units if necessary.
  8. Enter Date Activated. This is necessary in order for the rule to function. 
  9. Enter the Expiry Date. This is not necessary for new rules.
  10. Enter the ICD-10 Code that should always be billed for the procedure to this payer.
  11. Select Remove in the Operation field.
  12. Click the  Post Edit button to save.
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.
  1. Select [*] in the Ins Payer field.
  2. Enter 99000 in the Block Code field.
  3. Enter 99000 in the Substitute Code field.
  4. Enter Date Activated, today.
  5. Select Remove in the Operation field.
  6. Save your new rule.

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.