Setup
Modifier rules
Decide which modifiers your claim lines get, in what order, and which ones billers only see as suggestions.
Payers often need two-character modifiers on a claim line, such as the therapy modifier for the discipline or a modifier for telehealth. Modifier rules record which modifiers each kind of claim line gets, so staff do not have to remember them. A line holds at most four modifiers.
Open Setup > Billing setup > Modifier Rules.
The built-in rules#
Every clinic starts with these rules. You can edit them or turn them off with Active, but you cannot delete them.
| Rule | What it does |
|---|---|
| Speech, occupational and physical therapy plan of care | Adds GN, GO or GP to every line of that discipline, for every payer. |
| Medicare therapy threshold reached | Adds KX for Medicare and Medicare Advantage once the patient's yearly therapy amount passes the threshold. |
| Occupational therapy assistant services | Adds CO for Medicare and Medicare Advantage when an occupational therapy assistant furnished more than 10 percent of the service. |
| Payer telehealth modifier | Adds the telehealth modifier the payer's billing rules name (95 or GT), only on telehealth lines. |
| NCCI distinct procedural service | Suggests XU or 59 when two codes on the claim form an NCCI pair that a modifier can separate. |
What a rule can match#
Every part you leave empty matches any line.
| Setting | Matches |
|---|---|
| Payers | All payers, one or more payer types (such as Medicare), or one payer. |
| Discipline | Lines of that discipline only. |
| Delivery | In person or telehealth, or only one of the two. |
| Procedure codes | Lines with one of these codes. Leave empty for every code. |
| Diagnosis codes | Lines with a diagnosis that starts with one of these codes. F80 covers F80.0, F80.81 and every other code under F80. |
| Rendering provider credential | Lines whose rendering provider holds one of these credentials, such as COTA. |
| Provider level | Lines whose delivering provider's credential has one of these education levels, for level modifiers such as HM or HO. |
| Minimum and maximum age | Patients whose age on the date of service falls in the range, both ends included. |
| Condition | One of the conditions in the note above. |
| Start and end dates | Dates of service from the start date to the end date, both included. Leave the end date empty to keep the rule going. |
Add a rule#
- Click New Modifier Rule.
- Enter a Name staff will recognize.
- Choose the Action: Add to the claim line, or Suggest only so billers see the modifier but NeatPractice never adds it.
- Choose the Category that sets the rule's place in the order (see below).
- Fill in what the rule applies to.
- Under Modifiers, pick up to four modifiers in the order they go on the line. Type a two-digit modifier such as
95to add it. Or choose The payer's telehealth modifier so the rule follows the payer's billing rules. - Optionally choose a Preferred position for the rule's first modifier.
- Set the Start date and, if the rule should stop, the End date.
- Click Create Rule.
NeatPractice checks each letter modifier and each procedure code against the code lists on the start date and tells you which ones are not valid then.
How NeatPractice orders the modifiers#
Modifiers the clinician entered on the line keep the first places. Then each matching rule adds its modifiers in category order:
- Payment-affecting (such as
CO) - NCCI
- Therapy discipline (
GN,GO,GP) - KX threshold
- Telehealth
A rule with a Preferred position takes that place when it is free, and the next free place when it is not. Each modifier appears once. When more than four modifiers match, NeatPractice keeps the first four and lists the ones it left off.
A different order for one payer#
Some payers want the modifiers in another order.
- Click Payer Order.
- Choose the Payer.
- Move the categories up or down.
- Click Save Order.
To go back to the default order, choose the payer and click Use Default Order.
Test a claim line#
Click Test a Claim Line to check your rules before a claim goes out. Choose a payer, a date of service, a procedure code and anything else the line would carry, then click Test Line. Search Diagnosis codes by code or description and pick up to 12 from the code list. NeatPractice shows the modifiers it would add, in order, the rule behind each one, and what it would only suggest. Nothing is saved, and the test needs no patient. If you change the line afterwards, the result is dimmed and marked as the previous test until you click Test Line again.
When you search for a code, the list says how many codes match when there are more than it shows; type more of the code or description to narrow it. Each modifier you pick is checked against the date of service, so one that is not valid then, or is about to retire, is named under the field.
Rates for a modifier#
A rule does not set a price. When a payer pays a different rate for a code with a modifier, such as CO, add a line
for that code and modifier to the payer's fee schedule.
Export and print#
Click Export CSV to download the list as a spreadsheet file, or Print for a PDF of the list. See Import, export and print.