Multiple Procedure Discounting Tab

File Maintenance Help for NextGen® Enterprise 8

Modifier Reimbursement Tab

You can determine surgical reimbursement based on a percentage of the charge amount. The Modifier Reimbursement tab enables you to create a series of modifiers and modifier combinations that are associated with a percentage reduction of allowed amount. If the system cannot find the exact CPT4 code and modifier combination on the Fee Schedule tab, it uses the percentage on the Modifier Reimbursement tab. For example, the scenario under which this tab would be referenced is as follows: You enter a charge and specify a two-digit modifier. The system attempts to find the row in the Contracts library Fee Schedule tab, but the CPT4 code and modifier combination that was entered does not exist in the contract. The system attempts to find the row in the Fee Schedule tab by using only the CPT4 code without the modifier and succeeds. The system attempts to find the row in the Contract Modifier Reimbursement tab using only the modifier that was specified on the charge entry screen and succeeds. T

File Maintenance Help for NextGen® Enterprise 8

General Tab of Contract Library Maintenance

The General tab of Contract Library Maintenance window consists of the following sections: Contract Information Contract Defaults Alerts and Edits Allowed and FFS/Balance Distribution Automatic Adjustments Contract Information Contract Defaults Alerts and Edits Allowed and FFS/Balance Distribution Automatic Adjustments Parent topic: Access Contract Library Maintenance

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

Help Guide for NextGen® Enterprise PM 8

Multiple Procedure Discounting in Cost Estimation

Multiple procedure discounting refers to the payment reduction applied to the allowed amount if the rendering provider performs multiple procedures on a single patient. You can configure the percentage of reduction on the allowed amount in a particular sequence of the procedure in the File Maintenance contract library. Set Up Multiple Procedure Discount You can set the percentage of reduction in the allowed amount in a particular sequence in the contract library from File Maintenance. Multiple Surgery Discounting The allowed amount is reduced for CPT®4 codes enabled with multiple surgery discounts. The discount is calculated in conjunction with the sequence of CPT®4 codes and the corresponding modifier percentage on the fee schedule. Endoscopy Discounting Multiple procedure discounts for endoscopy work in conjunction with the multiple procedure discount and base CPT®4 code fields on the Fee Schedule tab. Scenarios - Determining Allowed Amount The system uses a hierarchy to compare CPT®

Help Guide for NextGen® Enterprise PM 8

Allowed Amount for Multiple Surgery

The following example illustrates how the allowed amount is determined in cost estimation for Multiple Surgery when modifier reimbursement and multiple procedure discounts are applied. Assume that the pricing for the following CPT®4 codes is set in the SIM Library: SIM / CPT®4 Code Price 35371 $1600 35456 $800 37207 $900 37208 $400 In the Contract Library > Fee Schedule tab: CPT4 Code Multiple Proc Discounting Allowed 35371 Multiple Surg (Yes) $800 CPT®4 Code Multiple Proc Discounting Allowed 35456 Multiple Surg (Yes) $400 CPT®4 Code Multiple Proc Discounting Allowed 37207 Multiple Surg (Yes) $450 CPT®4 Code Multiple Proc Discounting Allowed 37208 Multiple Surg (No) $200 In the Contract Library > Modifier Reimbursement tab: Modifier 59 (Distinct Procedure/Service) and/or Modifier 80 (Assist Surgeon) are defined as reducing the allowed amount to 25% of the amount defined in the contract fee schedule. In the Contract Library > Multiple Procedure Discounting tab: Multiple Procedure Discou

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

Multiple Procedure Discounting Tab

Recommendations

Modifier Reimbursement Tab

General Tab of Contract Library Maintenance

Set Up a Fee Schedule for Contract Payers

Multiple Procedure Discounting in Cost Estimation

Allowed Amount for Multiple Surgery

Multiple Surgery Discounting