Roll-Up Billing

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

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

Behavioral Health Billing

In NextGen® Enterprise PM, you can setup the billing requirements for Behavioral Health Billing. Behavioral health SIM codes are set up in the Service Items Library with a base minute value of 15, 30, 60, 240, or a custom value. In addition, the price per time unit is defined for each SIM code. During charge posting, behavioral health SIM codes prompt for the entry of a start and stop time, and then total time units for the charge are calculated based on the times entered. Payers are set up in the Payers master file with a base minute rounding method that is used to round the total time entered on each charge up or down when calculating time units. When multiple behavioral health charges on a single encounter have the same CPT4 code, the same modifiers, the same base minutes and the same unit price, those charges roll-up, or bundle, into a single line item on the claim. The total units on the claim for the roll-up line item is calculated using the total time entered on all of the indiv

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

Roll-Up Billing by CPT4 Code

Roll-Up Billing by CPT4 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 CPT4 code. This option is rarely used. It could be used for any payer that requires multiple services to be rolled-up to a single CPT4 code line item on the claim. Note: Best practice is to use encounter rate billing for both Medicare and Medicaid. In some cases, roll-up by CPT4 code will not meet the billing and claim requirements for a payer (e.g. FQHC/RHC 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 the setup, all SIM codes on an encounter with the same Alternate CPT4 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-up charges. In order for ch

File Maintenance Help for NextGen® Enterprise 8

CPT4 Roll Up

A CPT4 roll up combines the total charges for SIMs using the same CPT4 code into a single charge. If you enter an alternate CPT4 code for a SIM designated to perform CPT4 roll up, the application combines the charges with the alternate CPT4 code. To combine the total charges from SIMs using different CPT4 codes, each SIM included in the roll up must be mapped to the same alternate CPT4 code. You can perform line item roll-ups in the following instances: The separate line item charges are totaled. The quantity of line item charges are "rolled up" to become a single charge. CPT4 roll up is used primarily by CHC (Community Health Clinic) clients. The CPT roll up takes multiple line items that are flagged and have the same CPT code or alternate CPT code and rolls them up into a single line item and changes the quantity to one – the total sum of the charges appears on the line item. Activate a CPT4 Roll Up Parent topic: Payer Tab - SIM Library

Roll-Up Billing

Recommendations

Charge and Billing Options for Health Centers

Encounter Rate Billing

Behavioral Health Billing

Roll-Up Billing by Revenue Code

Roll-Up Billing by CPT4 Code

CPT4 Roll Up

Charge and Billing Options for Health Centers

Encounter Rate Billing

Behavioral Health Billing

Roll-Up Billing by Revenue Code

Roll-Up Billing by CPT4 Code

CPT4 Roll Up