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 |
Extended CPT®4 code (greater than 5 characters) in Cost Estimation but not in Contract
| Cost Estimation | Contract Library |
|---|
| CPT®4 Code | Mod 1 | Mod 2 | Mod 3 | Mod 4 | Fee Schedule Tab | Modifier Reimbursement Tab |
| 453805951 | 59 | 51 | | | 45380 | 5951 |
- 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 . 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 . 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 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 Estimation | Contract Library |
|---|
| CPT®4 Code | Mod 1 | Mod 2 | Mod 3 | Mod 4 | Fee Schedule Tab | Modifier Reimbursement Tab |
| 45380 | 59 | 51 | | | 453805951 | 5951 |
- 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.
Note: The modifiers could have also defaulted from the SIM code but that is irrelevant.
- 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 . The allowed amount defined for the 9-digit CPT®4 code is used.
- The 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 Estimation | Contract Library |
|---|
| CPT®4 Code | Mod 1 | Mod 2 | Mod 3 | Mod 4 | Fee Schedule Tab | Modifier Reimbursement Tab |
| 45380 | 59 | 51 | | | 45380 | 5951 |
- 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.
Note: The modifiers could have also defaulted from the SIM code but that is irrelevant.
- 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 and fails that value.
- The system takes the CPT®4 code from the cost estimation (45380) and does a lookup on the . 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 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 Estimation | Contract Library |
|---|
| CPT®4 Code | Mod 1 | Mod 2 | Mod 3 | Mod 4 | Fee Schedule Tab | Modifier Reimbursement Tab |
| 45380 | 59 | 51 | | | 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.
Note: The modifiers could have also defaulted from the SIM code but that is irrelevant.
- 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.
Note: The modifiers could have also defaulted from the SIM code but that is irrelevant.
- 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 and fails to find that value.
- The system takes the CPT®4 code from the cost estimation (45380) and does a lookup on the . 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 tab. It fails to find that value so the original allowed amount for the 5-digit CPT®4 code is used.
