Create and Manage Service Billing Profiles

  • Updated

Every service in the RCM must have at least one service billing profile set up to instruct the system on creating the claim when the service is recorded. In other words, if the claim were a pie, the service billing profile would be the recipe for making the pie. Let's review billing profiles together! 

 

User Permissions

Only users with admin-level profiles can create and manage service billing profiles. For more information on user profiles and permissions, click here. 

Billing Profile Types and Settings

Service Billing Profiles are configured for institutional and professional services. In contrast, non-medical services do not require a billing profile since they will always be created as a private pay claim (patient billable). Let's compare institutional billing profiles to professional billing profiles in the RCM.

  • Institutional Billing Profiles always require the Revenue Code and Bill-Type Prefix when creating claims. Adjustments to the revenue code will always occur within the billing profile; however, a claim form rule and a service grouping rule are available to update the bill-type prefix without adjusting the billing profile. 
  • Professional Billing Profiles always require the Claim Form Service Name, Place of Service, and HCPCS/CPT when creating professional claims. While the claim form service name is required, it will only display on a claim in conjunction with a claim form rule. Additionally, a service group rule is available to update the place of service without adjusting the billing profile. However, any changes made to the HCPCS/CPT must occur within the profile. 
  • Ensure each billing profile has compatible settings for users who want to allow more than one service on a claim. 
    1. This setting is used for medication-related services. 
    2. This setting is used for medication-related services. 
    3. Allows a claim to have more than one service on a claim. 
    4. Allows a claim to have more than one unit recorded for the service on the same date. 
    5. Allows the claim to contain more than one service date.
    6. Allows multiple service dates that span more than one month to be on a claim.
    7. Itemizes institutional claims. 
    8. Itemizes professional claims. 
    9. Allows a claim to indicate if the patient's condition was present at admission. 
    10. This setting is used for medication-related services. Click here for more information on NDC codes. 

Create Service Billing Profiles

Every service created will have a default billing profile assigned, but how and when the system uses that profile will depend on the type of service. Standalone services use the default billing profile to create the claim. U/R-required services use the service billing profile referenced within the patient's U/R plan. 

Create Institutional Service Billing Profiles

  1. In the Practice Admin, click Service.
  2. Next, click on the desired service.
  3. In the Service window, click Billing Profiles.
     
  4. Next, click Create Service Billing Profile.
     
  5. Input the Profile Name and update the Default Claim Payer dropdown when appropriate.
  6. Toggle on Require Preferred Claim Type to limit the claim form creation to only the designated Preferred Claim Type.
  7. Input the Institutional Revenue Code and Bill-Type Prefix.
  8. When applicable, include the HCPCS/CPT Code and Institutional Modifier.
  9.  Update the HCPCS Unit Measurement Basis from Days to Units when appropriate.
     
  10. Toggle on/off any of the following settings for additional configuration.
  11. Finally, click Create to complete the process.
     

Create Professional Billing Profiles

    1. In the Practice Admin, click Services.
    2. Next, click on the desired service.
    3. In the Service window, click Billing Profiles.
       
    4. Next, click Create Service Billing Profile.
       
    5. Add the Profile Name and Claim Form Service Name.
    6. Toggle off Require Preferred Claim Type if you do not want to limit the claim form creation to only the designated Preferred Claim Type.
    7. Next, update the Professional Place of Service.
    8. Then change the HCPCS Unit Measurement Basis from Days to Units when appropriate.
       
    9. Toggle on/off any of the following settings for additional configuration.
    10. Click Create.
    11. In the Billing Profiles screen, click on the Profile Name.
    12. Next, click Professional Service Lines.
    13. Click Create Service Line.
    14. Input the HCPCS/CPT Code.
    15. Add any Modifiers when appropriate.
    16. If more than one professional service line will be referenced, update the Order to instruct the system which HCPCS/CPT code to use first.
       
    17. Finally, click Create to complete the process.
       

Manage Service Billing Profiles

Let's review how to manage service billing profiles in the RCM! 

Manage Institutional Billing Profiles

  1. From the Practice Admin, click Service.
  2. Next, click on the Service Name.
  3. In the Service window, click Billing Profiles.
  4. Click on the Profile Name.
  5. If you wish to alter the billing profile from its original configuration, click Baseline. This will generate corrections for all claims created using the billing profile.
  6. If you wish to alter the billing profile to affect only certain claims based on their service date, click Create Scheduled Change Set.
  7. Input the Effective Date and click Save.
  8. Next, click the pencil icon.
  9. Make the desired changes to any fields and/or settings and click Save to complete the process. 

Manage Professional Billing Profiles

    1. From the Practice Admin, click Services.
    2. Next, click on the Service Name.
    3. In the Service window, click Billing Profiles.
       
    4. In the Billing Profiles window, click on the Profile Name.
    5. To change the billing profile, follow steps 4-10 from the Manage Institutional Billing Profiles instructions. 
    6. To change the Professional Service Line reference, click Professional Service Lines.
    7. Then click on the HCPCS/CPT Code you'd like to update,
    8. If you wish to alter the billing profile from its original configuration, click Baseline. This will generate corrections for all claims created using the billing profile.
       
    9. If you wish to alter the billing profile to affect only certain claims based on their service date, click Create Scheduled Change Set.
    10. Input the Effective Date and click Save.
    11. Next, click the pencil icon.
    12. Make the desired changes to any fields and/or settings and click Save to complete the process.
       

Was this article helpful?

0 out of 0 found this helpful

Comments

0 comments

Article is closed for comments.