Create a Service, Billing Profile, and Set Facility Rates

Services are the level of care and ancillary services you provide to patients and bill for, including insurance and private pay charges. Services are created at the Practice-level. You can further determine how a particular service is billed using Service Billing Profiles and Combined Service Sets.  

When creating a service, you will:

1. Create the service and set whether a UR plan is required.
2. Create a billing profile for the service to determine how it's billed. Additional Billing Profiles can be added if needed.
3. There is an additional step required for services billed as Professional that allows you to set up the service code and modifiers as needed.
4. Configure the service rates.

Create a Service

1. From the Admin menu, choose Practice Admin.
2. Open the Services tab and click Create Service.
3. From the Create Service window:
   
1. Billing Classification: Set the service to:
   • Medical/Behavioral: For Insurance billed services.
   • Non-medical: For Private pay billed services.
2. Name the service as the procedure code and revenue code suggests. A good naming convention for most codes is the three-letter acronym (DTX, PHP, etc.) or other easily discernable items like OP-Group, OP-Individual, Case Management, or Drug Screening. 
   • For Kipu EMR integration: Ensure that the Service Name in AveaOffice matches the Level of Care Name or Service Description in EMR, and please don't use parenthesis in the description to prevent errors in matching the codes between the systems. 
3. Add a Description for the service to appear on the patient statement. You can copy and paste the verbiage from the Name, or you can lengthen the acronyms to the complete service name, e.g., RTC would become Residential Treatment.
4. Level of Care: Set the correct level of care for the service using the drop-down. The levels of care in this list are system defaults and cannot be modified. 
5. Attendance Calendar: Use the toggle to choose:
   • Enabled/On: A utilization plan must be entered at the patient-level before this service can be billed out. Use this for any services that may require pre-authorization numbers.
   • Disabled/Off: The service never requires a utilization plan and is recorded in the Attendance Calendar under Select Standalone Services.
   • A Few Things to Note: This field is not required for Non-Medical services. Additionally, this field cannot be edited once the service is created.
6. Is Active: This toggle allows the service to be billed. Disable if you no longer offer this service at your organization or you don't want it available for billing yet.
4. Click Create. 

Kipu EMR Integrated Services

When creating Medical/Behavioral services for organizations integrated with the Kipu EMR, there is an additional drop-down available that will pull in Ancillary (Kipu Services) or Level of Care (Kipu Levels of Care) services from the EMR.

This field is used to help match the services between the two systems to ensure the proper service is billed. The system can also match services using the Name field in Avea and the Code Description field in the Kipu EMR, so we recommend these match exactly.  

Create a Service Billing Profile

After creating the service, the next step is to create the Service Billing Profile. This profile determines how the service is billed on the claim. 

1. Locate the service on the Services list. This list is sorted alphabetically by name.
2. Open the newly created service and select the Billing Profiles tab.
3. Click on Create Service Billing Profile.
4. From the Create Service Billing Profile window, complete the following fields:
1. Profile Name: Select a name that will be easily distinguishable by users. This is what you will see in the U/R plan when selecting the billing profile. We recommend “All Payers” for standard profiles. If it’s payer-specific, enter the payer’s name.
2. Claim Form Service Name: This can go onto the claim form with a claim rule in place. This field should be appropriate to send to the payer to accurately describe the service. 
3. Default Claim Payer: Choose Medical, Behavioral, or Insurance Home Plan. This selection determines which payer the service will be routed to.
4. Preferred Claim Type: Choose Institutional (UB-04), Professional (CMS-1500), or Private Pay. This selection determines which claim form the service will be sent on.
   
5. Require Preferred Claim Type: Enable this toggle if the claim should only ever be sent on the selected Preferred Claim Type. We recommended enabling this setting.
6. Institutional Revenue Code: This is required for institutional claims.
7. Institutional HCPCS/CPT Code: This may be needed for institutional claims, but is not required.
8. Institutional Bill Type Prefix: This is required for institutional claims.
9. Institutional Modifier: This may be needed for institutional claims, but is not required.
   
10. Professional Place Of Service: Select a Place of Service (only used if the service is being sent professionally).
11. HCPCS Unit Measurement Basis: This setting is important for the claim file that is sent to the clearinghouse. Select Days for Detox and Residential levels of care, and Units for all other levels of care.
12. Allow Partial Units: Enable this toggle if the service needs to bill fractional units to account for precise dosages. This setting allows users to use decimal points to enter exact milligrams of medication and should only be used for Medication services.
13. Allow Zero Units: Enable this toggle if the service can have zero units. This allows users to account for medication dispensing on claims with zero designated units. This setting should be used for Medication, Administration, or Dispensing services only.
14. Allow Multiple Services Per Claim: Leave toggled Off if only one service should go out on the claim form. Toggle On if you want to bill this service with other services on the same claim form.
    
15. Allow Multiple Units Per Date: Toggle On to allow the service to be billed with multiple units in one day. Leave toggled Off to help ensure that a day-long service won’t get billed twice in one day. This helps with claim generation and prevents denials for incorrect billing. 
16. Allow Multiple Dates Per Claim: Toggle Off if a certain service should be sent for only one date of service. This will never allow the same service to be billed on a claim with more than one date of service. The default for this option is Yes.
17. Itemize 837I Claims: Toggle On if the service always needs to be sent on the institutional claim as itemized. This means if a claim has multiple dates of service, each date will have its own line item. 
18. Itemize 837P Claims: Toggle On if the service always needs to be sent on the professional claim as itemized. This means if a claim has multiple dates of service, each date will have its own line item. 
    
19. Write Present on Admission Indicator:  Toggle On if the admission indicator should be added to the diagnosis code on claim forms. This option can be toggled Off to exclude the admission indicator.
20. Sequence Priority: This setting allows you to determine the order of services that are billed on claims together. The lowest values appear on the claim first, whereas the highest value appears last. For example, you want to bill Individual Therapy on the same day as an Add-On service. In that case, you can set up a Combined Service Set and ensure that the Individual Therapy service is on Line 1 by setting the sequence priority to 90 for Individual Therapy. The default for this option is to leave the sequence priority set to 100. 
21. Is Active: To deactivate a billing profile (remove it from the user’s view) you will need to toggle this to No. 
5. Click Create.

Multiple Billing Profiles

Most services will have a single billing profile for all payers. However, there are scenarios where a particular payer only accepts specific information for a service. If this occurs, you can create an additional billing profile specifically for that payer.

For U/R Required Services, both billing profiles will be available for selection when setting up the UR plan. For non-U/R required services, please contact Customer Support to set up a claim rule ensuring the correct coding goes on the claims.

Professional Services

If the service will be billed out as Professional, complete the following steps to add a Professional Service Line after the billing profile has been created. Otherwise, skip to the Set Facility Rates section below.

1. Once the Service Billing Profile is created, click on the Profile Name.
2. Open the Professional Services Lines tab.
3. Click Create Service Line. 
4. In the dialogue box, enter the HCPCS/CPT code and add a modifier, if needed. Modifiers are generally used for standalone telehealth services.
   
   • Note: The Order field is no longer necessary and can be ignored.
5. Click Create.  

Don't create more than one professional service line for a billing profile. This will result in duplication of the code and rate during claim creation.

Set Facility Rates

The next step to make sure all created services can be used is to set the service rate for each Facility under Practice Admin. Note: You can only have one rate per Service Billing Profile. Check out our article Facilities to see how to reference the newly created service and set rates.

1. Navigate to Practice Admin and open the Facilities tab.
2. Select the Facility Name.
3. Open the Facility Services tab.
4. Click Add Service Reference.
5. Choose the Service from the drop-down menu and then select the Service Billing Profile to associate a facility rate.
   
6. Next, complete the rate information.
   
   1. Enter an Institutional/Patient Billing Unit Rate. 
   2. If this is a Professional service and you've configured Professional Service Lines, you'll also be able to include a Professional Unit Rate. If you don't see this section, please review the Professional Services section above to add a Professional Service Line. 
7. Once this information is entered, click Add. 
8. The service will now be an option to select in the utilization plan or attendance calendar for standalone services based on what type of service was created.

If the Service has more than one billing profile, ensure that each billing profile has a service facility rate set. 

Service Rate Types

By default, all services are created with a Date of Service rate type. You can adjust the service rate type to Admit Date as needed for billing. Note: This only impacts Medical/Behavioral service types (does not apply to Private Pay). 

To make this change:

1. Navigate to Practice Admin > Facilities.
2. Open the Facility and select Facility Services.
3. Click on the Service Reference.
4. Click on the Service Rate Type Change button.
5. Select the desired rate type and click Submit.
   
6. When Patient Admit Date is selected as the Service Rate Type, any scheduled change set for that service rate reference will be based on the patient’s admit dates in lieu of the date of service.