Modifier Reimbursement in Cost Estimation

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®

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

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

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

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

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

Modifier Reimbursement in Cost Estimation

Recommendations

Multiple Procedure Discounting in Cost Estimation

Modifier Reimbursement Tab

Multiple Surgery Discounting

Scenarios - Determining Allowed Amount

Allowed Amount for Multiple Endoscopy Procedures

Allowed Amount for Multiple Surgery

Modifier Reimbursement in Cost Estimation

Multiple Procedure Discounting in Cost Estimation

Modifier Reimbursement Tab

Multiple Surgery Discounting

Scenarios - Determining Allowed Amount

Allowed Amount for Multiple Endoscopy Procedures

Allowed Amount for Multiple Surgery