Allowed Amount for Multiple Surgery

SIM / CPT®4 Code	Price
35371	$1600
35456	$800
37207	$900
37208	$400

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

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

Help Guide for NextGen® Enterprise PM 8

Allowed Amount for Multiple Endoscopy Procedures

The following example illustrates how the allowed amount is determined in cost estimation for multiple endoscopic procedures by base CPT®4 code when modifier reimbursement and multiple procedure discounts are applied. 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 a Base CPT®4. Assume that the pricing for the following CPT®4 codes is set in the SIM Library: SIM / CPT®4 Code Price 45378 $700 45385 $600 45380 $500 45381 $400 In the Contract Library > Fee Schedule tab: CPT®4 Code Multiple Proc Discounting Base CPT®4 Code Allowed 45378 No N/A $200 CPT®4 Code Multiple Proc Discounting Base CPT®4 Code Allowed 45385 Multiple Surg (Yes) 45378 $300 CPT®4 Code Multiple Proc Discounting Base CPT®4 Code Allowed 45380 Endoscopy (Yes) 45378 $250 CPT®4 Code Multiple Proc Discounting Base CPT®4 Code Allowed 45381 Endoscopy (Yes) 45378 $225 In the Contract Library > Modifier Reimbursem

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

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

File Maintenance Help for NextGen® Enterprise 8

Multiple Procedure Discounting Tab

The Multiple Procedure Discounting tab is used to reduce the allowed amount by the percentage specified in the table according to the sequence of the procedure. The tab works in conjunction with the Multiple Proc Discount and Base CPT4 Code fields on the Fee Schedule tab. Parent topic: Access Contract Library Maintenance

Help Guide for NextGen® Enterprise PM 8

Endoscopy Discounting

When endoscopic-related procedures are performed, the allowed amount is adjusted based on the amount of the base CPT®4 code. When you set the Multiple Proc Discounting field in the Fee Schedule, select Endoscopy and specify the base CPT®4 code. Allowed Amount for Multiple Endoscopy Procedures Allowed amount for multiple endoscopic procedures is determined by base CPT® code. Parent topic: Multiple Procedure Discounting in Cost Estimation

Allowed Amount for Multiple Surgery

Recommendations

Multiple Surgery Discounting

Allowed Amount for Multiple Endoscopy Procedures

Multiple Procedure Discounting in Cost Estimation

Modifier Reimbursement in Cost Estimation

Multiple Procedure Discounting Tab

Endoscopy Discounting

Multiple Surgery Discounting

Allowed Amount for Multiple Endoscopy Procedures

Multiple Procedure Discounting in Cost Estimation

Modifier Reimbursement in Cost Estimation

Multiple Procedure Discounting Tab

Endoscopy Discounting