Set Up the General Billing Rule Options
- Open File Maintenance.
- Select Libraries > Encounter Rate Billing.
The Encounter Rate Billing List window opens.
- Do one of the following:
- To add a library, select the open menu button
and then select New.
- To modify a library, select the library from the list, select the open menu button
The Encounter Rate Billing Library Maintenance window opens. - To add a library, select the open menu button
- Select the General tab.
- In the Encounter Rate Exempt setting, do the following:
- Disqualify patient encounter from ER billing if: Select one of the following options to set the basis for disqualifying an encounter from encounter rate billing:
- All SIMs are ER exempt
- Only one SIM is ER exempt
- Suppress claim for disqualified patient encounter: Select this option to suppress the claim for any encounter that is disqualified from encounter rate billing based on exempt SIM codes.
Note: Encounter Rate Exempt settings apply only when one or more of the charge line SIM codes are flagged as Enc rate exempt in the Service Items library
- Disqualify patient encounter from ER billing if: Select one of the following options to set the basis for disqualifying an encounter from encounter rate billing:
- In the Multiple Patient Encounters per day setting, select one of the options from the list to determine how multiple same day or same payer encounters are selected for billing to the encounter rate payer. This setting applies only when a patient has more than one encounter on the same day with the same encounter rate payer.
- PM Selection: Select this option to enable the system to automatically flag the first same day or same payer encounter identified during the billing process as Multi-Yes on the Billing & Collections tab of the Encounter Maintenance window. A claim is created for the Multi Yes encounter. Other same day/same payer encounters for the patient are suppressed from creating claims, if the Suppress claim for multiple same-day encounters option is enabled on the Primary Encounter Rate tab.
- Manual Selection: Select this option to have users determine which same day/same payer encounter should be billed. The user manually flags each encounter as either Multi Yes or Multi No on the Billing & Collections tab of the Encounter Maintenance window. A claim is created for the Multi Yes encounter. Other same day/same payer encounters for the patient flagged as Multi No are suppressed from creating claims, if the Suppress claim for multiple same-day encounters option is enabled on the Primary Encounter Rate tab.
- PM Select All: Select this option to have the system automatically flag all same day/same payer encounters identified during the billing process as Multi Yes on the Billing & Collections tab of the Encounter Maintenance window. A claim will be created for all Multi Yes encounters.
- In the Alternate Payer setting, select the Do not insert ER SIM for alternate payer claims option to prevent the ER SIM from appearing on the alternate payer claim. If this option is unchecked, the ER SIM appears on the main payer claim and the alternate payer claim. This setting applies when the ER payer has CPT4 codes that are billed to an alternate payer.
- In the Encounter Rate Insertion setting, select the Insert ER SIM into Encounter Maintenance option to insert and store the ER SIM and value amount on the Billing & Collections tab of the Encounter Maintenance window rather than inserting the ER SIM on the Charge Posting window as a unique service line. This option makes charge-based reports more accurate because the ER SIM code is not inserted as an additional charge.