Blocked and Substituted Codes
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Last Modified on 08/10/2021 12:58 pm EDT

Version 20.5

The Block and Substitute feature has been replaced with the Advanced Workflow Rules Engine (OP AWARE). 

To view the map for OP AWARE, click here. 

Version 20.4

About Blocked and Substituted Codes

Path: Billing tab > More button (Customize group) > Coding Substitution Rules

The Blocked and Substituted Codes window creates payer specific rules to:

  • Block CPT codes and substitute with the payable alternative
  • Automatically add modifiers to CPT codes
  • Remove CPT codes when they appear on a superbill

Blocked and Substituted Codes Map

Number
SectionDescription

1

Function ButtonsThe Function buttons print a record, insert a record, remove a record, edit a record, save/post an edited record, and cancel the edited record.

2

Expand GridThe grid can be expanded by selecting the Expand Grid checkbox.

3

Grid FieldsThe grid lists the insurance payers. The CPT codes are added below the insurance payers in the grid. The grid fields contain all the blocks where the data is viewed, entered, or modified. The fields include the following:
  • Block Code: Search for the CPT code to block.
  • Substitute Code: Search for the CPT that will replace the blocked CPT code.
  • Modifier 1,2,3,4: Select the modifier to bill out with the CPT (optional).
  • EPSDT: Select if an EPSDT referral is required Yes or No (optional).
  • EPSDT2: Select if an additional follow up visit is required (optional).
  • Unit: Enter the unit count if it is different for this payer for this CPT code (optional).
  • Date Activated: Select the date for the system to begin blocking this CPT code.
  • Expiry Date: Select the date for the system to no longer block the CPT code (not used for new entries).
  • ICD10: Enter the diagnosis code needed to ensure payment with 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 (ex: modifiers).
    • Add: Allows a single CPT code to be converted into more than one service.
    • Remove: Blocks the CPT but does not substitute with another CPT code. The blocked code will be ignored when it occurs for the specified payer.

Note: Remove (-) Blocks the CPT but does not substitute with another CPT code. The blocked code will be ignored when it occurs for the specified payer. If you are manually inputting charges a warning will appear that the CPT is not supported by the selected payer. If converting electronic charges, the CPT code will not appear on the claim.


Tags: CPT Codes

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