How are billing rules applied?

How are billing rules applied?

Billing Rules are applied in a hierarchical order where the most specific setting will win for a given note. There are 4 Billing Rules Selections & 3 areas the billing rule may be set.


Billing Rule Locations

  1. Global Settings - Located at "Settings" => "Documentation" => "Default Billing Rule". This sets the generic fallback value for the entire system. This will be used if the billing rule is not specified anywhere more specific. If all 3 locations state "Not Specified" The Commercial (15-Minute) rule will be used.
  2. Insurance - Located at "Lists" => "Insurance Companies" => {Select an insurance} => "Billing" tab => "Billing Rule" - Will override the global settings for any note whose parent case has this insurance as primary during the note date. Note that if an insurance is marked as "medicare" this setting will be ignored and the "medicare" rule will be used.
  3. Case - Located at "Lists" => "Cases" => {Select a case} => "Case Info" => "Billing Rule". Will force all notes of the given case to use the specified method ignoring insurance and global settings.


Billing Rule Selections

  • Not Specified - The billing rule will fall back to the more general setting or the commercial rule if all 3 locations have this value.
  • Commercial (15-minute) - The standard round-up rule. While usually 15-minutes this rule will calculate units using the formula: ceiling( {minutes} / {Time Per Unit} ). That is the minutes of the individual charge divided by the time per unit setting stored in the procedure always rounded up. For example: assuming the time per unit is the standard 15, 1-15 minutes = 1 unit, 16-30 minutes = 2 units, etc. The Time Per Unit may be set at "Billing" => "Procedure Codes" => {select procedure code} => "General" => "Time Per Unit". The value will default to 15 minutes if left empty.
  • AMA - Also know as the 8-Minute AMA rule, the units are calculated with the formula: round(minutes/15). This is the minutes divided by 15 then rounded using the standard 5-up rounding rule (see chart example below).
    8-Minute Rule

    0-7 Minutes
    0 Units
    8-22 Minutes
    1 Unit
    23-37 Minutes
    2 Units
    38-52 Minutes
    3 Units

  • Medicare - Often just called "8-minute rule" uses the same calculations as the AMA system on a per charge basis. However the Medicare 8-minute rule requires the total minutes to follow the formula instead of the individual charges. QuickEMR is unable to automatically judge which charges should be increased or decreased to meet the totals so manual adjustments will be required by the user to insure compliance (see screenshot).  Also note that if insurance is set to Medicare the Billing Rule will be ignored and the Medicare option will be assumed.


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