Encounter Rate Billing in NextGen® Enterprise PM

Help Guide for NextGen® Enterprise PM 8

Setting Up Encounter Rate Billing

Encounter rate billing in NextGen® Enterprise PM involves the following setup in System Administrator and File Maintenance: Security Access Rights Enterprise Preferences Practice Preferences CPT4 Codes Revenue Codes Departments Service Items Library Claim Edits Library Transaction Codes Encounter Rate Billing Library Payers Set Up Security Access Rights for Encounter Rate Billing Set Up Enterprise Preferences for Encounter Rate Billing Practice Preferences for Encounter Rate Billing Add or Modify CPT4 Codes for Encounter Rate Billing Add or Modify Revenue Codes for Encounter Rate Billing Add or Modify Departments for Encounter Rate Billing Add or Modify SIM Codes for Encounter Rate Billing Set Up Claim Edits for Encounter Rate Billing Add or Modify Transaction Codes for Encounter Rate Billing Add or Modify an Encounter Rate Billing Library Set Up Payers for Encounter Rate Billing Parent topic: Encounter Rate Billing

Help Guide for NextGen® Enterprise PM 8

Encounter Rate Billing Status

When an encounter is created, the Billing Status field on the Encounter Maintenance window on the Billing & Collections tab in the Encounter Rate sub-tab defaults to Undecided for primary, secondary and tertiary encounter rate billing. Billing Status Once the encounter is billed, the Billing Status automatically changes to indicate the action taken: ER Applied, Exempt, or Non ER Payer. Encounter Maintenance Encounter Rate Billing Statuses include the following: Status Description Undecided Indicates the encounter has not yet been billed. This is the default status used when an encounter is created. ER Applied Indicates the encounter was billed and that encounter rate billing was applied during the billing process. Exempt Indicates the encounter was billed and that encounter rate billing was not applied during the billing process because it was exempt due to the billing rules setup. Multi Yes Used when multiple same day encounters exist for the same encounter rate payer. This status is

Help Guide for NextGen® Enterprise PM 8

Encounter Rate Billing

Encounter Rate Billing is an option for payers such as Medicare (FQHC and RHC) and Medicaid that have very unique and specific billing and claim requirements, and that reimburse at a flat encounter rate. Encounter Rate Billing provides the ability to automatically adjust charges so that the balance reflects the payer’s expected encounter reimbursement rate or amount. In addition, an encounter rate code required by the payer on claims can be automatically inserted onto each encounter. For example, a 0521 Revenue Code line item may be required on Medicare UB/837I claims, and a T1015 CPT4 Code line item may be required on Medicaid 1500/837P claims. The setup and configuration of the Encounter Rate Billing library also defines which of the original charge line items on an encounter are included on the claim. Note: FQHC practices must use encounter rate billing for Medicare. It is the only option available that meets CMS’s complex requirements and guidelines for claims. The encounter rate b

Help Guide for NextGen® Enterprise PM 8

Encounter Rate SIM Narrative for Claims

The Narrative field on the Charge Posting window, or on the Encounter Rate sub-tab on the Billing & Collections tab of the Encounter Maintenance window, can be used to enter a free-text narrative, or comment, for the ER SIM code on the encounter. This populates the narrative segment for the ER SIM on claims for the primary, secondary or tertiary encounter rate payer. Charge-Level Narrative To include a charge-level narrative for an ER SIM on claims, the Encounter Rate Billing library for the payer must include the following settings on the Claims tab: Display narrative on ER SIM charge Line? = Yes From what field should the narrative data pull from? = Charge Entry If a narrative exists on the Charge Posting window for the ER SIM charge line, then it is used on the claim. If the narrative for the ER SIM charge line is blank, then the narrative for the first charge line is used on the claim. Charge Posting Encounter-Level Narrative To include an encounter-level narrative for an ER SIM on

Help Guide for NextGen® Enterprise PM 8

Practice Preferences for Encounter Rate Billing

To use encounter rate billing in NextGen® Enterprise PM, specific options must be enabled for the practice in Practice Preferences. Enable Qualifying Encounter Billing Process Date for Encounter Rate SIM and Adjustments Parent topic: Setting Up Encounter Rate Billing

Help Guide for NextGen® Enterprise PM 8

Enable Qualifying Encounter Billing

The Encounter Rate Billing functionality in NextGen® Enterprise PM includes logic that identifies multiple encounters for a patient on the same date of service at the same location with the same encounter rate payer. Qualifying Encounter Billing must be enabled for the practice. When enabled, the Encounter Rate Billing Status fields display on the Billing & Collections tab of the Encounter Maintenance window. These fields are used to determine which encounter to bill when a patient has multiple same-day encounters with more than one provider at the same location with the same encounter rate payer attached. Access NextGen® Enterprise PM. From the Admin menu, select Preferences, and then Practice. The Practice Preferences window opens. From the Preference List, select Claims. Select the Enable Qualifying Encounter Billing check box. To save changes and close the window, select OK. Parent topic: Practice Preferences for Encounter Rate Billing

Encounter Rate Billing in NextGen® Enterprise PM

Recommendations

Setting Up Encounter Rate Billing

Encounter Rate Billing Status

Encounter Rate Billing

Encounter Rate SIM Narrative for Claims

Practice Preferences for Encounter Rate Billing

Enable Qualifying Encounter Billing

Setting Up Encounter Rate Billing

Encounter Rate Billing Status

Encounter Rate Billing

Encounter Rate SIM Narrative for Claims

Practice Preferences for Encounter Rate Billing

Enable Qualifying Encounter Billing