Billing Rules

Billing Rules

Billing Rules - auto-build charges from order tests

Use Billing Rules to automatically translate ordered tests into billable CPT charges when invoices are created. Rules evaluate who is being billed and what was ordered, then add the correct CPT codes and units. Give each rule a clear, meaningful Name-this appears on invoices for transparency.

What rules can use

  • Bill To: Insurance, Client, Patient (Self-Pay)
  • Bill Type: Insurance, Client Bill, Patient Bill
  • Payer (insurance company)
  • Client (ordering account)
  • Patient (specific patient)
  • Tests ordered:
    • Specific test(s)
    • Test count thresholds (e.g., N tests)
    • Test classification (e.g., drug classs)

What rules do

  • Add one or more CPT codes
  • Set Units per CPT (including tiered or count-based units)
  • Trigger at invoice/claim creation so charges are built consistently

📘 Create a Billing Rule

  1. Go to Billing → Billing Rules
  2. Name the rule (this name will show on invoices).
  3. Define Scope:
    • Bill To, Bill Type, Payer, Client, Patient (as needed).
  4. Define Test Criteria:
    • Choose specific tests, a minimum/maximum count, or a classification.
  5. Add Actions:
    • CPT code(s) and Units to create when criteria are met.
  6. Save and test with a sample order/invoice preview.

Examples

  • Client-bill screening bundle
    • Scope: Bill Type = Client; Client = ABC Clinic
    • Criteria: Classification = Barbiturates
    • Action: Add CPT X with 1 unit; CPT Y with 1 unit
  • Volume-based unit rule
    • Scope: Bill To = Insurance; Payer = XYZ Health
    • Criteria: Test Count ≥ 10 in Chemistry
    • Action: Add CPT Z with Units = test count

How Billing Rules interact with other billing features

  • Price Rules: After charges are created, matching Price Rules override the CPT price.
  • Modifier Rules: Can auto-apply modifiers (e.g., 90, QW, 91) to the created CPTs.
  • Permitted Diagnosis Rules: Validate CPT-to-ICD medical necessity before export.

Best practices

  • Keep rules specific to avoid overlap; document the contract/policy in the rule notes.
  • Prefer classification-based rules for toxicology.
  • Test new/edited rules in a non-production workflow or with previews before go‑live.
  • Review rules periodically for payer/client contract changes.

Troubleshooting

  • Charge didn’t create: Confirm the rule’s scope matches the order’s Bill To/Type/Payer/Client and that the test criteria are met.
  • Duplicate charges: Check for overlapping rules; consolidate or narrow scopes.
  • Wrong units: Verify unit logic (count thresholds) and that test counts/classifications are configured correctly.

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