MPFS

Overrides the internal Conversion Factor entered in our system for Medicare.

Note: This field is used for managed care products.

Applies the rules for endoscopy services paid under the MPFS.

Applies the Multiple Procedure Payment Reduction (MPPR) logic for selected diagnostic services paid under the MPFS.

Applies the Multiple Procedure Payment Reduction (MPPR) logic for selected therapy services. This logic only applies if more than one therapy code is billed.

• The therapy code with the highest charged amount is priced using the MPFS Therapy Reduction Rate linked to the carrier/locality.
• The remaining therapy codes are priced at the Therapy PE Reduction Rate that is linked to the carrier/locality.

Provides the option to apply the 2% Medicare sequestration reduction to that contract.

Instructs the system to calculate anesthesia charges as minutes instead of units for Virginia Medicaid.

Defines the percentage of the fee schedule that will be used in calculations for Medicare services. The value can be up to 12 characters long, including the decimal.

Note: This field is used for Managed Care products.

Defines the percentage of the fee schedule that will be used in calculations for Medicare services. The value can be up to 12 characters long, including the decimal.

Note: This field is used for Managed Care products.

Defines the percentage of the fee schedule that will be used in calculations for Medicare services. The value can be up to 12 characters long, including the decimal.

Note: This field is used for Managed Care products.

Defines the percentage of the fee schedule that will be used in calculations for Medicare services. The value can be up to 12 characters long, including the decimal.

Note: This field is used for Managed Care products.

Defines the percentage of the fee schedule that will be used in calculations for Medicare services. The value can be up to 12 characters long, including the decimal.

Note: This field is used for Managed Care products.

Defines the percentage of the fee schedule that will be used in calculations for Medicare services. The value can be up to 12 characters long, including the decimal.

Note: This field is used for Managed Care products.

Defines the percentage of the fee schedule that will be used in calculations for Medicare services. The value can be up to 12 characters long, including the decimal.

Note: This field is used for Managed Care products.

The carrier is a five digit number that pulls the fee schedules linked to the specific product.

• Use this function if the customer is not using the zip code in Field 32. SERVICE FACILITY LOCATION INFORMATION on CMS1500 claims.
• If the customer is using the zip code then leave this field blank.

Note: TRICARE and Government Program's Medicaid are linked to the Medicare carrier/locality in our system.

The percentage of the physician fee schedule amount reimbursed for clinical nurse services.

• The default values is set at Medicare percentage.
• TRICARE and Pennsylvania Medicaid should be changed to 100%.
• All other products follow the Medicare rules.

The percentage of the physician fee schedule amount reimbursed for clinical psychologist services.

• TRICARE and Pennsylvania Medicaid should be changed to 100%.
• All other products follow the Medicare rules.

The percentage of the physician fee schedule amount reimbursed for clinical social worker services.

TRICARE and Pennsylvania Medicaid should be changed to 100%.

All other products follow the Medicare rules.

Click CPT Code Range to enter specific pricing for CPT codes outside the service types in the reimbursement tool for Medicare Managed Contracts. Clicking this button opens a table of code ranges.

• Enter the first code in the range in the Code From field and the last code in the range in the Code To field.
• Enter the reimbursement for this code range as a percentage of the fee schedule.
• Enter the effective date of the fee schedule you want to use. If no date is specified, the most recent fee schedule is used.
• Click Back to close the code range tool.

Note: Values entered in this range tool override any other reimbursement values selected or entered in the rest of the reimbursement tool.

When selected, charges are not consumed when a code prices to $0.00 in the MPFS reimbursement tool. This is used when $0.00 pricing from the MPFS node is needed roll to another reimbursement tool for pricing.

Note: This option defaults to Unselected.

This option allows you to choose not to force Modifier 26 for Medicare.

Note: Modifier 26 refers to the professional component of a procedure. For example, the interpretation of a lab test.

Instructs the system to reduce payment per line item by the e-prescribing discount percentage defined for your facility for codes with an e-prescribing discount indicator for Medicare.This percent reduction takes place after all other reimbursement logic has been applied.

Note: This option is not available for Medicaid or TRICARE.

Instructs the system to reimburse claims according to facility rates for Medicare Managed Care contracts.

The date the Fee Schedule becomes effective.

Note: This function is generally used for Managed Care contracts that stipulate fee schedules that are specific to an effective date.

For example, if the contract reads Medicare FS 2002 you would enter 20020101 in the fee schedule effective date field.

The percentage allowable for a licensed psychologist.

When checked, limits repricing to five surgery codes. Check box defaults to selected.

The preferred locality code. The locality is a two digit number that pulls the fee schedules linked to the specific product.

• Use this function if the customer is not using the zip code in Field 32. SERVICE FACILITY LOCATION INFORMATION on CMS1500 claims.
• If the customer is using the zip code then leave this field blank.

Note: TRICARE and Government Program's Medicaid are linked to the Medicare carrier/locality in our system.

Defines which code from the fee schedule is used to calculate reimbursement for Medicaid Managed Care:

• Pay last known – Use the code with the latest Date of Service.
• Pay first occurrence – Use the code from the first year in which it appears in the fee schedule.
• Pay highest reimbursing – Use the code that pays the highest reimbursement amount.
• Pay lowest reimbursing – Use the code that pays the lowest reimbursement amount.

The percentage of costs allowed for an individual who does not fit any other the other categories.

Instructs the system to reimburse claims according to non-facility rates for Medicaid Managed Care.

The percentage of the physician fee schedule amount reimbursed for nurse midwife services.

• TRICARE and Pennsylvania Medicaid should be changed to 100%.
• All other products follow the Medicare rules.

The percentage of the physician fee schedule amount reimbursed for nurse practitioner services.

• TRICARE and Pennsylvania Medicaid should be changed to 100%.
• All other products follow the Medicare rules.

Percentage of allowable for other extender.

• TRICARE and Pennsylvania Medicaid should be changed to 100%.
• All other products follow the Medicare rules.

The preferred service date. Use MM/DD/YYYY format. Overrides the service date on the claim with the date you enter. You can use the anchor date instead of this option.

Instructs the system to price the line item at 100% of gross charges.

The percentage of charges allowed if full reimbursement is not allowed.

The reimbursement percentage allowed.

The percentage of the physician fee schedule amount reimbursed for physician assistant services.

• TRICARE and Pennsylvania Medicaid should be changed to 100%.
• All other products follow the Medicare rules.

Instructs the system to reimburse claims according to the rates specific to the place of service for Medicare. This is the default selection.

The name of the insurance product selected:

• Medicare
• Medicaid
• TRICARE

Note: Medicaid Products: Virginia, North Carolina, Iowa, Pennsylvania, Oklahoma, and Nebraska.

Instructs the system to reimburse claims according to established Medicare rules

The percentage of the physician fee schedule amount reimbursed for resident services.

• TRICARE and Pennsylvania Medicaid should be changed to 100%.
• All other products follow the Medicare rules.

The percentage of the physician fee schedule amount reimbursed for senior physician services.

• TRICARE and Pennsylvania Medicaid should be changed to 100%.
• All other products follow the Medicare rules.

Do not use. This option has not been programmed in or system.

Instructs the system to apply modifier reductions to reimbursement calculations for Medicare.

Instructs the system to apply multiple procedure reductions to reimbursement calculations for Medicare.

Instructs the system to use limiting charges for providers that do not participate in Medicare.

Note: This option is not available for Medicaid.

Instructs the system to pay $0.00 for any CPT code specified as “Not used for Medicare Pay” in the National RBRVS table. If not selected, CPT codes are priced at the fee schedule rate. This field defaults to unselected.

Instructs the system to use Relative Value Unit (RVU) ranking for Medicare logic and rules for specific codes.