This article reviews the process of setting up Modifier and NDC rules. These rules are used to dictate which modifiers and/or NDCs should be defaulted for specified CPT codes based on Providers, Locations, Insurance Profiles, or the presence of another specified CPT code.
Note: NDC setup is only for PM Only users. EHR users should refer to How to Bill an NDC Code for a list of EHR options.
An alternate option for defaulting modifiers in the EHR is to use Administration: Procedure Panels in the EHR setup.
- From the menu bar, click Admin and then click Modifier and NDC Management.
Create a New Modifier
- Click New Modifier Rule.
- Alternatively, click the Copy as New icon to copy an existing rule.
- Enter a name for the rule.
- Select Providers, Locations, and Insurance Profile options for the rule.
- If Selected Provider(s) is chosen, add providers by clicking on the desired provider(s) and then clicking Add.
- If Selected Location(s) is chosen, add locations in the same manner.
- If Selected Profile(s) is chosen:
- Add a Payer Class by making a selection from the list and clicking Add.
- Add a Payer Name by searching using the text box and then making a selection, or by choosing a Payer Name from the list and clicking Add.
- Add a Plan Name by searching using the text box and then making a selection, or by choosing a Plan Name from the list and clicking Add.
- Click Next to proceed.
- Search for Procedure Codes using the search feature, or by selecting from the Procedure Code Category list and then from the Procedure Codes list.
- Click Add as Billed Code" or Add as Present Code. If Add as Billed Code is selected, that code will receive the modifier. Add as Present Code is an optional selection that should be used if the default modifier is dependent upon the existence of another CPT code.
- Click Add New Rule to add another rule.
- Click Save Modifier Rule when finished.
Edit a Modifier
- Click the "Edit" icon to edit the selected rule.
Delete a Modifier
- Click the Delete icon to delete the selected rule.
Charge Entry Modifier Rules
- In Charge Entry, if the Billed Code precedes the service line of the Present Code, the user must click the Modifier Rules to apply the modifier rules.
- If the Present Code precedes the service line of the Billed Code, the modifier rules will be applied as the service lines are entered.
