Daily Charge Grouping

The Daily Charge Grouping reimbursement tool allows you to define reimbursement for services that are based on a per visit basis (with a single date of service) and where multiple visits can be billed on the same claim.

Infusion therapy is an example of this type of service where the visit is separated from any associated pharmacy, lab, or radiology charges for the visit. If the infusion therapy appears on the claim, the reimbursement is handled differently for the related drug, lab, or radiology charges than if the infusion therapy is not present.

The Daily Charge Grouping term matches contract specifications against claim data. Procedure codes are one of the data types matched, and matching is performed at three points in the process:

To qualify a day for reimbursement under the term
To qualify a detail charge or claim revenue item for payment
To choose a base amount from a fee schedule to calculate payment

Each of these matching processes considers the modifiers associated with a procedure codes to make the correct match. When choosing a base amount from a fee schedule to calculate payment, the reimbursement tool first looks for an exact match of the code plus the modifier. When an exact match is not found, the reimbursement tool then looks for the same code without the modifier for matching purposes. If the code is specified in the tool without a modifier, the code is matched, even when billed with a modifier.

The Event Properties section of the Daily Charge Grouping tool lets you define the revenue, CPT, HCPC, or CDM code(s) that identify the per visit service or event, such as infusion therapy.
The remaining sections of the tool let you define the reimbursement for any charges associated with the event.
To type a value in the Codes to Group for Reimbursement or the Calculation Method Value field, click the field and press Enter without making a selection from the list.
For more information about specific fields on this page, refer to the Field Descriptions table below.

Field Descriptions

The following table describes the fields on the Daily Charge Grouping reimbursement tool.

Field	Description
Event Properties Section	Allows you to define the code(s) that identify the per visit service or event, such as infusion therapy.
Detail Charges UB Lines	Allows you to determine whether detailed charges or UB lines should be used to identify the event. If you are using a CPT/HCPC code to identify the event, and your facility does not include CPT/HCPC codes on the UB, you must select Detail Charges.
Revenue Code CPT/HCPC Code CDM Code	Allows you to select the type of code or codes you want to use to identify the event. For example, selecting Revenue Code identifies all codes that you enter in the Condition field as revenue codes.
Manual Entry	Allows you to mix revenue, CPT/HCPC, or CDM codes in the same condition statement by using three tokens specific to this reimbursement tool.
Table	Allows you to select a table from the Table field as your condition statement rather than listing specific codes or ranges of codes.
Condition	Allows you to define the specific code or codes you want to use to identify the event. You can type a single code, a series of codes, or a range of codes. You can separate codes, series, or ranges by typing “AND”, “OR”, or a comma. A comma separator implies an “OR” separator. For example, 612,614 is read by the system as 612 or 614. Entering a range also implies an “OR” separator. For example, 612-614 is read by the system as 612, 613, or 614.
	With Revenue Code, CPT/HCPC Code, or CDM Code selected, the option button identifies the type of code. You don’t have to enter a token to identify the type of code. For example: Typing 350 requires the claim to include code 350. Typing 612,615,350 requires the claim to include either code 612, 615, or 350. Typing 350 OR 612-615 requires the claim to include code 350, 612, 613, 614, or 615. Typing 350 AND 612-615 requires the claim to include code 350 and either 612, 613, 614, or 615.
	With Manual Entry selected: Because the option button does not identify a code type, you must use the following tokens to identify the code type. CDMRevHas – identifies the codes that follow this token as revenue codes. CDMProcHas– identifies the codes that follow this token as procedure (CPT/HCPC) codes. CDMHas – identifies the codes that follow this token as CDM codes. You can combine code types as well as combining “OR” and “AND” statements in the same condition. Use brackets {} when entering a range or series with these tokens. For example: Typing CDMProcHas 408 AND CDMRevHas {404-406} requires the claim to include procedure code 408 and either revenue code 404, 405, or 406.
Consume All Charges on the Matched Days	Provides the option to consume all charges with the same service date as the selected code or codes that identify the event. This check box defaults to selected. If you clear this check box, the charges with the same service date that are not specifically addressed by this tool are not consumed and roll to the next matching service type in the profile.
Reimbursement Limit	Allows you to limit reimbursement to billed charges when using a fee schedule so that reimbursement is capped at billed charges even if the fee schedule amount is greater.
Limit Reimbursement to Percent of Charges	Provides the option to cap the reimbursement at the code line item level to the billed charges or a percentage thereof, even if the fee schedule amount is greater.
Reimbursement Group	Allows you to select the type of related codes you want to define reimbursement for.
Detail Charges UB Lines	Allows you to determine whether detailed charges or UB lines should be used to identify the event. If you are using a CPT/HCPC code to identify the event, and your facility does not include CPT/HCPC codes on the UB, you must select Detail Charges.
Revenue Code CPT/HCPC Code CDM Code	Allows you to select the type of code or codes you want to define reimbursement for.
Grouping Details Section
Codes to Group for Reimbursement	Allows you to select the specific codes you want to define reimbursement for. This should include any charges associated with the event, such as pharmaceuticals, lab, radiology, and so on. You can type a single code (612), a series of codes (612,615,350), or a range of codes (612-620) in this field. You can also select a lookup table to include any codes listed in the selected table. To type in this field, click the field and press Enter without making a selection from the list. You can also type “Remaining” in this field to define reimbursement for all remaining codes with the same service date as the event that are not specifically listed in the tool.
Calculation Method Type	Allows you to define whether to reimburse the selected codes according to a percentage, a flat rate, or a fee schedule.
Percent of	Allows you to specify a percentage of the fee schedule at the line item level. This field is only available if you selected Fee Schedule from the Calculation Method Type list.
Calculation Method Value	Allows you to define the specific reimbursement values for the selected code(s). If you selected Fee Schedule from the Calculation Method Type list, you can select the desired fee schedule. If you selected Flat Amount or Percentage from the Calculation Method Type list, you can type the desired percentage or flat rate amount. To type in this field, click the field and press Enter without making a selection from the list.
Per Unit	Allows service types using Fee Schedules to price either per unit or once per day. Select Yes to price the codes found in the range, list, or table per unit. Select No to price the codes found in the range, list, or table once per day. Note: This option is not available for the Flat Amount or Percentage calculation methods.
Limit Type	Allows you to define the type of limit or cap, if any, that you want to apply to this reimbursement. You can select one of the following values: NGT - Flat – No greater than the specified flat amount entered in the Limit Value field. NGT - Percentage – No greater than the specified percentage entered in the Limit Value field. This is a percentage of the billed charges associated with the codes to group for reimbursement selected for that line only. NLT - Flat – No less than the specified flat amount entered in the Limit Value field. NLT - Percentage – No less than the specified percentage entered in the Limit Value field. This is a percentage of the billed charges associated with the codes to group for reimbursement selected for that line only.
Limit Value	Allows you to enter the specific flat rate or percentage to use as a limit or cap for the reimbursement.
Line Item Opportunity	Displays the variance amount (total line item reimbursement - line item charge) when a code's billed charges are less than the expected line item reimbursement.