Multiple Procedure Discounting in Cost Estimation

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

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

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

Help Guide for NextGen® Enterprise PM 8

Reimbursements and Discounts in Cost Estimation

The insurance payers pay the health care providers through a system of reimbursement. Most of the times, the heathcare providers apply discounts on the final bill. The reimbursements and discounts that can be applied to the total cost are: Modifier reimbursement Multiple procedure discounting Multiple surgery discounting Endoscopy discounting Modifier Reimbursement in Cost Estimation You can determine surgical reimbursement based on a percentage of the charge amount. Multiple Procedure Discounting in Cost Estimation You can specify the multiple procedure discount on the allowed amount based on a particular sequence of the procedures. Parent topic: Pre-Services Cost Estimation

Help Guide for NextGen® Enterprise PM 8

Set Up Multiple Procedure Discount

In File Maintenance, open Libraries > Contract Parent topic: Multiple Procedure Discounting in Cost Estimation

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

Multiple Procedure Discounting in Cost Estimation

Recommendations

Modifier Reimbursement in Cost Estimation

Multiple Surgery Discounting

Endoscopy Discounting

Reimbursements and Discounts in Cost Estimation

Set Up Multiple Procedure Discount

Scenarios - Determining Allowed Amount

Modifier Reimbursement in Cost Estimation

Multiple Surgery Discounting

Endoscopy Discounting

Reimbursements and Discounts in Cost Estimation

Set Up Multiple Procedure Discount

Scenarios - Determining Allowed Amount