Example: Roll-Up Billing by Revenue Code for Medicare (RHC)

Charge	Revenue Code	Amount	Preventive/Non-Preventive
99212	0521	$95.00	Non-Preventive
11301	0521	$150.00	Non-Preventive
76090	0403	$200.00	Preventive

Help Guide for NextGen® Enterprise PM 8

Roll-Up Billing by Revenue Code and Transactions

The following charges are entered on an example Medicare (RHC) encounter: Charge Revenue Code Amount Preventive/Non-Preventive 99212 0521 $95.00 Non-Preventive 11301 0521 $150.00 Non-Preventive 76090 0403 $200.00 Preventive Charge Posting When the encounter is billed, a UB/837I claim is created for Medicare Part A that meets the specific billing requirements for an RHC. The appearance of the claim is a result of parameters defined within thePayertab of theService Itemslibrary. Claim Line 1: Includes the Revenue Code (0521) and no CPT4/HCPCS code. The total charge amount is equal to the sum of all non-preventive services that rolled-up because they have the same revenue code. Claim Lines 2 - n: Preventive services are listed separately on the claim with their corresponding revenue code, CPT4/HCPCS code, and charge amount. Claims Medicare remits a $90.00 encounter rate payment on the 0521 revenue code line item. Because the encounter does not include the 0521 line item, the payment must

Help Guide for NextGen® Enterprise PM 8

Roll-Up Billing by Revenue Code

Roll-Up Billing by Revenue Code provides the ability to roll-up multiple charges on an encounter into one line item on the claim. Each line item represents a specific revenue code. This setup could be used for Medicare at a Rural Health Center to create a claim where all non-preventive services are rolled-up to a single 0521 revenue code line item. Important Note: Best practice is to use Encounter Rate Billing for both Medicare and Medicaid. In some cases, Roll-Up by Revenue Code will not meet the billing and claim requirements for a payer (e.g. FQHC Medicare). Before proceeding with the setup for roll-up billing, always consult with a NextGen Healthcare Implementation Specialist and a Claims Analyst to confirm that this is the best setup option to meet the payer's specific billing requirements. With this setup, all SIM codes on an encounter with the same revenue code will roll-up to a single line item on a claim and the amount on that line item will equal the total sum of the rolled-u

Help Guide for NextGen® Enterprise PM 8

Example: Roll-Up Billing by CPT4 Code

The following charges are entered on an example encounter: Charge Alt CPT4 Code Amount Preventive/Non-Preventive 99212 0521 $95.00 Non-Preventive 11301 0521 $150.00 Non-Preventive 76090 $200.00 Preventive Charge Posting When the encounter is billed, a UB/837I claim is created. The appearance of the claim is a result of parameters defined within the Payer tab on the Service Item library. Claim Line 1: Includes the CPT4/HCPCS code (0521). The total charge amount is equal to the sum of all services that rolled-up because they have the same Alternate CPT4 Code (0521). Claim Lines 2 - n: Other services are listed separately on the claim with their corresponding CPT4/HCPCS code and charge amount. Claims Line Parent topic: Roll-Up Billing by CPT4 Code

Help Guide for NextGen® Enterprise PM 8

Roll-Up Billing by CPT4 Code and Transactions

The following charges are entered on an example encounter: Charge Alt CPT4 Code Amount Preventive/Non-Preventive 99212 0521 $95.00 Non-Preventive 11301 0521 $150.00 Non-Preventive 76090 $200.00 Preventive Charge Posting When the encounter is billed, a UB/837I claim is created. The appearance of the claim is a result of parameters defined within thePayertab on theService Itemslibrary. Claim Line 1: Includes the CPT4/HCPCS code (0521). The total charge amount is equal to the sum of all services that rolled-up because they have the same Alternate CPT4 Code (0521). Claim Lines 2 - n: Other services are listed separately on the claim with their corresponding CPT4/HCPCS code and charge amount. Claims Line The payer remits a $90.00 payment on the 0521 CPT4/HCPCS code line item. Because the encounter does not include the 0521 line item, the payment must be posted manually against the original charges. Adjustments are also posted manually against the original charges so the appropriate balances

Help Guide for NextGen® Enterprise PM 8

Roll-Up Billing

Roll-Up Billing is an option for payers such as Medicare (RHC only) and Medicaid that have very unique and specific billing and claim requirements, and that reimburse at a flat encounter rate. Roll-Up Billing provides the ability to roll-up multiple charges on an encounter into a single line item on the claim. The amount on that line item will equal the total sum of the rolled-up charges. The roll-up can be done by revenue code (for example, 0521) or by CPT4 Code (for example, T1015). Note: Best practice is to use Encounter Rate Billing for both Medicare and Medicaid. In some cases, roll-up billing will not meet the billing and claim requirements for a payer (e.g. FQHC Medicare). Before proceeding with the setup for roll-up billing, always consult with a NextGen Healthcare Implementation Specialist and a Claims Analyst to confirm that this is the best setup option to meet the payer's specific billing requirements. The roll-up billing considerations are as follows: Claims are not config

Help Guide for NextGen® Enterprise PM 8

Charge and Billing Options for Health Centers

In most cases, the special setup for Health Centers applies only to Medicare and Medicaid. This includes Managed Care programs for Medicare and Medicaid which are often considered to be commercial payers. Blue Cross Blue Shield and Commercial payers typically bill as Fee-for-Service on a 1500 claim form just like at other private practices. No special setup is required for these payers. However, every state has potential for exceptions. Therefore, any payer can be setup for encounter rate or roll-up billing if needed. Encounter Rate Billing: This is an option for payers such as Medicare (FQHC / RHC) and Medicaid that have 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/amount. In addition, an encounter rate code required by the payer on claims can be automatically inserted onto each en

Example: Roll-Up Billing by Revenue Code for Medicare (RHC)

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Roll-Up Billing by Revenue Code and Transactions

Roll-Up Billing by Revenue Code

Example: Roll-Up Billing by CPT4 Code

Roll-Up Billing by CPT4 Code and Transactions

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Charge and Billing Options for Health Centers