Set Up Modifier Reimbursement
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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
File Maintenance Help for NextGen® Enterprise 8
Modifier Reimbursement Setup
Parent topic: Modifier Reimbursement Tab
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
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
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
Retrieving Co-pay for Cost Estimation
If the practice is running in a real-time system, the system fetches the co-pay amount in the real-time eligibility (271) transaction file. If multiple co-pay amounts are found in the eligibility verification response, they are listed in the Estimate Patient Cost window. If your practice is running in a non-real-time system, the co-pay amount is obtained from the Insurance Maintenance window, Contract Exception Maintenance window, or Contract Library Maintenance window, based on a particular hierarchy system. Co-Pay from Insurance Information Based on the co-pay settings in the Payers master file in File Maintenance, co-pay amounts appear on the Insurance Maintenance window in NextGen® Enterprise PM. Your administrator must enable multiple co-pays by opening the Enterprise Preferences window, the General tab, and selecting the Enable multiple co-pays check box. On the Insurance Maintenance window, the co-pay amounts for cost estimation are as follows: Speciality co-pay information, suc
