Modifier Rules

Modifier Rules

Modifier Rules - auto-apply CPT/HCPCS modifiers

Use Modifier Rules to automatically apply the correct modifiers to CPT/HCPCS codes during charge creation/export. Automating common scenarios improves speed, accuracy, and payer compliance.

Benefits

  • Consistency: applies the same logic for all users and clients.
  • Fewer denials: aligns with payer policies (e.g., QW for waived tests, 90 for send-outs).
  • Efficiency: saves manual clicks and reduces missed modifiers.
  • Targeting: scope by payer, client, bill type, priority, and other conditions.

Common rules to automate

  • 90 Reference Lab for send-out tests.
  • QW for CLIA-waived assays.
  • 91 Repeat test on same day with new specimen/time.
  • 59 (or XE/XS/XP/XU) for distinct specimen/encounter/site when appropriate.
  • 92 Alternative platform for eligible POC devices.

đŸ“˜ How to create rules

  1. Open Billing → Modifier Rules.
  2. Click New and complete the fields (most are self-explanatory), typically including:
    • CPT code(s) and the Modifier to apply
    • Scope: Payer(s), Client(s), Bill Type, Bill To
    • Select Charge Type (Test, Additional Fee, Travel Fee, Billing Rule...), controls what category of charge can receive the modifier. The check box All charges applies the rule to all eligible charges of that type found in the order (instead of only a single targeted charge).
    • Select Effective Date
    • Select frequency select the appropriate frequency in days

    • If the modifier should only apply based on frequency:

      • Set Frequency (days):
        • 0 = frequency logic will not trigger (do not use 0 when you intend frequency behavior)
        • 1 = same-day frequency
        • 2 = within 2 days, etc.
    • CPT Codes: if additional CPT codes are selected the rule will apply the modifiers to the charge selected plus the selected CPT codes if available in the order.
    • Select the modifier(s) you want applied (up to 4 modifiers per rule)
  3. Save and test with a sample order; review in the billing preview/export.

Best practices

  • Start with high-impact, low-ambiguity rules (90, QW, 91).
  • Avoid blanket 59; require clear conditions and documentation.
  • Use effective/expiry dates and comments citing policy (LCD/NCD/payer).
  • Monitor rejections; refine rules or add exceptions.
  • Keep an override path for rare edge cases and log overrides.


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