How Special Billing Rules are Applied

For medications that are billed using different J-Codes or J-Code combinations depending on the quantity given, you can configure special billing rules for the application to apply. NextGen Healthcare recommends that you configure a special billing rule for every quantity that you expect to dispense or administer. If a rule is configured for the quantity given, the application applies that rule and bills accordingly.

If no rule is configured for the exact quantity given, the application calculates a combination of J-Codes to bill for that quantity, as follows:

It bills the J-Code associated with the largest configured Special Rule quantity that is equal to or less than the dispensed or administered quantity.
It subtracts the first billed quantity from the amount given.
It then bills the J-Code associated with the largest amount in the Special Billing rules grid that is equal to or less than the remainder.
It subtracts the next billed amount from the remainder.
It runs iterations of billing for and subtracting amounts until all the entire dispensed or administered amount is billed.
Example 1: 100 mgs are administered for a drug that has separate J-Codes for quantities of 20, 40, and 60 mgs as shown here:
- Billing would be 3 units of the J-Code associated with 60 mgs and 1 unit of the J-Code associated with 40mgs
Example 2:

100 mgs are administered for a drug that has rules set up for quantities of 20, 40, and 80 mgs as shown here:
- Billing would be: 1 unit of the J-Code associated with 80 mgs and 1 unit of the J-Code associated with 20 mgs

How Special Billing Rules are Applied

Recommendations

Add a Standard Billing Rule

Add a Special Billing Rule

Update Any Billing Rule

Configuring Billing Rules

Configuring Medication Information and Billing Rules

Configure Financial Classes That Do Not Allow Combining Medications

How Special Billing Rules are Applied

Add a Standard Billing Rule

Add a Special Billing Rule

Update Any Billing Rule

Configuring Billing Rules

Configuring Medication Information and Billing Rules

Configure Financial Classes That Do Not Allow Combining Medications