Modifier Reimbursement Tab

File Maintenance Help for NextGen® Enterprise 8

Set Up a Fee Schedule for Contract Payers

The Fee Schedule tab enables you to indicate the amount that you expect to be reimbursed for specific procedures that fall outside of the contract defaults. For example, the co-pay for a CPT4 code might be different from the default co-pay. The options on the Fee Schedule tab override the options on the General tab. The information entered applies when the payer attached to the contract is the primary payer for an encounter. Contractual requirements alerts can be set up to display during appointment scheduling, patient registration, and billing processes. Automatic contractual adjustments and the distribution of insurance reimbursement can be set up to be applied to patient balances. In File Maintenance, select Libraries, and then Contract. The Contracts List window opens. Double-click the applicable library, and then select the Fee Schedule tab. Enter a CPT4 Code. The CPT4 codes and their descriptions that are specific to each contract display in the CPT4/Desc list box. To search for

File Maintenance Help for NextGen® Enterprise 8

Add or Modify a Contract

In File Maintenance, select Libraries > Contracts. The Contracts Libraries window opens. To add a new contract, select open menu button and select New. The Contract Library Maintenance window opens. Enter the Contract Name, Effective Date, and Expiration Date. Enter default information for the Contract. Note: The Co-Payment on Office Enc.'s check box allows you to set a default co-pay amount. The amount entered here is the default used on the Insurance Maintenance window for any patients that have insurance associated with this contract. To enter a default co-payment, select the Co-Payment on Office Encounters check box and enter the dollar amount below it in the Default Co-Pay Amount box. Enter the information in the Automatic Adjustments section that applies. To add the CPT 4 code applicable to the contract, select the Fee Schedule tab. Then select open menu button or question mark. To find a CPT4 code, select open menu button and select Lookup to display a list of CPT4 codes and des

Help Guide for NextGen® Enterprise PM 8

Modifier Reimbursement in Cost Estimation

Surgical reimbursement is calculated based on a percentage of the charge amount. The contract allowed amount for procedures can be automatically reduced based on charge modifiers The contract allowed amounts for surgeries involving multiple procedures can be automatically reduced based on the charge order/sequence The contract allowed amount for endoscopy procedures can be calculated as the difference between the allowed defined for the "Billed CPT®4" and the allowed defined for the "Base CPT®4" When the allowed amount has been determined, it is then used in the standard calculation of the adjustment amount: [SIM Library Price]-[Contract Allowed Amount]=[Adjustment Amount] You can configure the modifier reimbursement in File Maintenance Libraries > Contract. The Modifier Reimbursement tab enables you to create a series of modifiers and modifier combinations that are associated with a percentage reduction of an allowed amount. If the system cannot find the exact CPT®4 code and modifier

Help Guide for NextGen® Enterprise PM 8

Scenarios - Determining Allowed Amount

The following scenarios describe the hierarchy used by the system to compare CPT®4 codes and modifiers on the Estimate Patient Cost window to those in the contract library to determine the allowed amount to be used for a service. Extended CPT®4 code (greater than 5 characters) in both Cost Estimation and Contract Library Cost Estimation Contract Library CPT®4 Code Mod 1 Mod 2 Mod 3 Mod 4 Fee Schedule Tab Modifier Reimbursement Tab 453805951 59 51 453805951 5951 The system looks at the CPT®4 code from the cost estimation (453805951) and determines that it is greater than 5 characters. This indicates that the modifiers are built into the CPT®4 code. The system takes the CPT®4 code from cost estimation and does a lookup in the Contract Library > Fee Schedule. It finds that the value (453805951) and the allowed amount defined for the 9-digit CPT®4 code are used. The Contract Library > Modifier Reimbursement is ignored since the modifiers were included in the CPT®4 code that was found on th

Help Guide for NextGen® Enterprise PM 8

Multiple Surgery Discounting

If the payer is linked to a contract and the CPT® code is enabled for multiple procedure discounting, then the allowed amount is reduced. The discount is calculated in conjunction with the sequence of CPT®4 codes and the corresponding modifier percentage on the fee schedule. Important: Ensure that you have enabled Multiple Surgery for multiple procedure discount Ensure that the modifier reimbursement percentage for the sequence has been set When you want to apply multiple surgery discounts on the allowed amount, the following can be used as reference: In the File Maintenance contract library, you set the following: Facility and non-facility amounts for the CPT®4 codes in the Fee Schedule tab Sequence indicator and modifier percentage in the Modifier Reimbursement tab In NextGen® Enterprise PM's Estimate Patient Cost window, submit the CPT®4 code for cost estimation. The system fetches the fee that is scheduled for the CPT®4 code. Based on the sequence that the CPT®4 code has been enter

File Maintenance Help for NextGen® Enterprise 8

Modifier Reimbursement Setup

Parent topic: Modifier Reimbursement Tab

Modifier Reimbursement Tab

Recommendations

Set Up a Fee Schedule for Contract Payers

Add or Modify a Contract

Modifier Reimbursement in Cost Estimation

Scenarios - Determining Allowed Amount

Multiple Surgery Discounting

Modifier Reimbursement Setup

Modifier Reimbursement Tab

Set Up a Fee Schedule for Contract Payers

Add or Modify a Contract

Modifier Reimbursement in Cost Estimation

Scenarios - Determining Allowed Amount

Multiple Surgery Discounting

Modifier Reimbursement Setup