NextGen Knowledge Center

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 EstimationContract Library
CPT®4 CodeMod 1Mod 2Mod 3Mod 4Fee Schedule TabModifier Reimbursement Tab
4538059515951  4538059515951

  • 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 the Fee Schedule tab.

Extended CPT®4 code (greater than 5 characters) in Cost Estimation but not in Contract

Cost EstimationContract Library
CPT®4 CodeMod 1Mod 2Mod 3Mod 4Fee Schedule TabModifier Reimbursement Tab
4538059515951  453805951
  • The system looks at the CPT®4 code from 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 fails to find that value.
    • The system extracts the first five characters from the cost estimation CPT®4 code (45380) and does a lookup in the Contract Library > Fee Schedule. It finds that CPT®4 code and the allowed amount.
    • The system extracts the modifiers from the cost estimation CPT®4 code (5951) and does a lookup on the Contract Library > Modifier Reimbursement tab. It finds that value and uses the defined Percentage of Allowed to reduce the allowed amount (for example, reduce to 25%).

Five Character CPT®4 Code in Cost Estimation and 9-character CPT®4 code in Contract

Cost EstimationContract Library
CPT®4 CodeMod 1Mod 2Mod 3Mod 4Fee Schedule TabModifier Reimbursement Tab
453805951  4538059515951
  • The system looks at the CPT®4 code from cost estimation (45380) and determines that it is only 5 characters. It then checks the individual modifier fields from the cost estimation and finds 59 and 51. This indicates that the CPT®4 and modifiers were entered separately during the cost estimation.
  • The system takes the CPT®4 code from cost estimation (45380) and adds the two modifiers 59 and 51 from modifiers fields which results in a value of (453805951). It does a lookup and finds that the exact value in the Contract Library > Fee Schedule. The allowed amount defined for the 9-digit CPT®4 code is used.
  • The Contract Library > Modifier Reimbursement tab is ignored since the modifiers were included in the CPT®4 code that was found in the Fee Schedule tab.

Five character CPT®4 code in both Cost Estimation and Contract with separate Modifiers

Cost EstimationContract Library
CPT®4 CodeMod 1Mod 2Mod 3Mod 4Fee Schedule TabModifier Reimbursement Tab
453805951  453805951
  • The system looks at the CPT®4 code from cost estimation (45380) and determines that it is only 5 characters. It then checks the individual modifier fields from cost estimation and finds 59 and 51. This indicates that the CPT®4 and modifiers were entered separately during cost estimation.
  • The system takes the CPT®4 code from cost estimation (45380) and adds the two modifiers 59 and 51 from the modifier fields which results in a value of (453805951). It does a lookup on the Contract Library > Fee Schedule and fails that value.
  • The system takes the CPT®4 code from the cost estimation (45380) and does a lookup on the Contract Library > Fee Schedule. It finds the CPT®4 code and the allowed amount.
  • The system takes the 59 and 51 modifiers from cost estimation and does a lookup on the Contract Library > Modifier Reimbursement tab. It finds that value (5951) and uses the defined Percentage of Allowed to reduce the allowed amount (for example, reduce to 25%).

Five character CPT®4 code in both Cost Estimation and Contract with separate Modifiers on charges only

Cost EstimationContract Library
CPT®4 CodeMod 1Mod 2Mod 3Mod 4Fee Schedule TabModifier Reimbursement Tab
453805951  45380 
The system looks at the CPT®4 code from cost estimation (45380) and determines that it is only 5 characters. It then checks the individual modifier fields from cost estimation and finds 59 and 51. This indicates that the CPT®4 code and modifiers were entered separately during the cost estimation.
  • The system looks at the CPT®4 code from cost estimation (45380) and determines that it is only five characters. It then checks the individual modifier fields from cost estimation and finds 59 and 51. This indicates that the CPT®4 code and modifiers were entered separately during the cost estimation.
  • The system takes the CPT®4 code from cost estimation (45380) and adds the two modifiers 59 and 51 from the modifier fields which results in a value of 453805951. It does a lookup on the Contract Library > Fee Schedule and fails to find that value.
  • The system takes the CPT®4 code from the cost estimation (45380) and does a lookup on the Contract Library > Fee Schedule. It finds that CPT®4 code and the allowed amount.
  • The system takes the 59 and 51 modifiers from cost estimation and does a lookup on the Contract Library > Modifier Reimbursement tab. It fails to find that value so the original allowed amount for the 5-digit CPT®4 code is used.