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®

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 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

File Maintenance Help for NextGen® Enterprise

Modifier Reimbursement Setup

You can reference the Modifier Reimbursement under the following scenarios: When you enter a charge and specify a two-digit modifier. In NextGen® Enterprise PM, there is a row in the Contracts library Fee Schedule tab, but the CPT4 code and modifier combination do not exist in the contract. In NextGen® Enterprise PM, there is a row in the Fee Schedule tab using only the CPT4 code without the modifier and succeeds. In NextGen® Enterprise PM, there is a row in the Contract Modifier Reimbursement tab using only the modifier that was specified on the charge entry window and succeeds. NextGen® Enterprise PM uses the row found in Fee Schedule, however it reduces the allowed amount by the percentage specified on the Modifier Reimbursement tab. All percentages from the reimbursement row are used to predict the payment amount, not the flat dollar amounts. Parent topic: Access Contract Library Maintenance

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

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

Modifier Reimbursement in Cost Estimation

Recommendations

Multiple Procedure Discounting in Cost Estimation

Modifier Reimbursement in Cost Estimation

Modifier Reimbursement Tab

Modifier Reimbursement Setup

Multiple Surgery Discounting

Multiple Surgery Discounting

Modifier Reimbursement in Cost Estimation

Multiple Procedure Discounting in Cost Estimation

Modifier Reimbursement in Cost Estimation

Modifier Reimbursement Tab

Modifier Reimbursement Setup

Multiple Surgery Discounting

Multiple Surgery Discounting