Procedure Code Reimbursement

Applies the multiplier(s) to all procedures

Indicates if anesthesia procedures are reimbursed

When selected, allows the ability to choose a lookup table

How the value is applied to codes in the table:

• Charge–to the charges associated with the code
• n/a–used in conjunction with $ Override value type
• Table–to the reimbursement amount for the code in the table

Dollar amount multiplied by units to calculate reimbursement

Applies the following options to the entire tool settings:

• Limit reimbursement to percent of charged–limits line-item reimbursement to the entered percentage of the charged amount. Reimbursement to line item charges is limited after all other logic has been applied to the reimbursement amount.
• Do not consume charges–provides the option not to consume charges. This is used for contract carve outs.
• Do not consume units–provides the option not to consume units. This is used for contract carve outs.

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.

Note: The service type must be loaded with the Procedure Code Reimbursement term and set to the Limit to Charge Amount option.

Determines the number of codes to reimburse. When selected, it limits the number of codes reimbursed to the number of multipliers specified in the Multiplier(s) table. When cleared, it allows all matching codes to reimburse; when the number of matching codes exceeds the number of multipliers, the last multiplier is applied to all remaining codes

Applies the Limitation, Secondary, and Subsequent rules that reduce the payment for non-primary procedures on the claim.

Indicates if medical/surgical procedures are reimbursed

Only applies the multiplier(s) to codes that appear on the claim with modifier 51

Applies the modifier first then determines the highest reimbursing code

Determines the code with the highest negotiated rate, then applies Modifier 50 for reimbursement

Modifier lookup table(s) used in calculating reimbursement. The list includes Universal tables and all modifier lookup tables in your facility

Modifier lookup table(s) used in calculating reimbursement. The list includes Universal tables and all modifier lookup tables in your facility

Percentage applied to the base amount in the table, charges or corresponding overridden amount

Indicates if the tool calculates reimbursement based on units associated with each code

Procedure lookup table(s) and/or fee schedule(s) used in calculating reimbursement. The list includes Universal procedure lookup tables and all procedure lookup tables in your facility.

Codes that ignore time reporting and only calculate based on the units in the RVU table

Indicates how reimbursement is calculated:

• Use procedure lookup table(s)–refers to the listed table(s) to calculate reimbursement for matching codes
• Use straight percentage–multiplies the entered percentage by the charge amount for each procedure code on the claim

Indicates how reimbursement is calculated:

• Use RVU table(s)–refers to the listed table(s) to calculate reimbursement for matching codes
• Use straight percentage–overrides the values of the matching codes with the percentage entered

Determines the order of reimbursement:

• Highest reimb.–reimburses the code with the highest reimbursement amount first
• Highest charge–reimburses the code with the highest charge first
• Do not sort–reimburses codes in the order in which they appear on the claim

Anesthesia-based procedure lookup table(s) used in calculating reimbursement. The list includes Universal procedure lookup tables and all procedure lookup tables in your facility

Determines how time is billed for anesthesia reimbursement:

• Units–by units
• Minutes–by minutes; must be converted to units
• Minutes per unit–sets the number of minutes per unit
• Initial unit offset–difference in time between the first time interval and subsequent time intervals
• Round to–determines how to round time

When selected, ignores codes that have a base amount of $0.00

Percentage or dollar amount applied to codes in the procedure lookup table(s)

Percentage of or override amount applied to the codes in the selected table(s). Conv. factor is not a valid option

For codes not round in the referenced table(s), indicates the action taken:

• Bypass procedure–ignores the code; does not calculate reimbursement for it
• Reject claim–rejects the entire claim
• Reimburse as zero–reimburses $0.00 for the code
• Use default percentage–applies the entered percentage to the charges associated with the code

For duplicate codes in multiple tables, indicates which code to reimburse:

• First code found–reimburses in the order in which the tables are listed
• Highest reimbursement–reimburses the code with the highest reimbursement amount
• Lowest reimbursement–reimburses the code with the lowest reimbursement amount