Procedure Lookup Table

For claims with CDM codes

Code type(s) that reflects the code type of the procedure lookup table used in the tool.

Except for CPT4 and HCPC, you typically do not select more than one at a time

Provides the option to calculate procedure code reimbursement by counting the procedure code lookup items to the second dollar stop loss threshold day rather than the entire length of stay. This check box is ignored if the claim does not qualify for stop loss.

Note: This option is only available if you selected the ICD9 check box.

For claims with CPT4 codes. Always selected in conjunction with HCPC

Provides the option not to consume charges. This is used for contract carve outs.

Provides the option not to consume units. This is used for contract carve outs.

For claims with DRG codes. This references a procedure lookup table that contains DRG codes–it does not reference a DRG weight table

For claims with HCPC codes. Always selected in conjunction with CPT4

For claims with ICD9 codes. When selected, some options are unavailable

Determines whether duplicate revenue codes are reimbursed:

• Yes–limits reimbursement to unique codes when duplicate revenue codes are found on a claim.
• No–reimburses all revenue codes, even if they are duplicate codes.

Note: This option is only active if you select the REV check box at the top of the reimbursement tool.

Determines the number of procedures to reimburse:

• Yes–limits the number of procedures reimbursed to the number of multipliers specified in the Multiplier table
• No–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

When selected, limits the reimbursement to the charged amount per line item

For claims with modifiers. When selected, the system refers to Modifier for instruction (refer to the Modifier description).

Used in conjunction with the MOD option (in the code types section)

• Type a modifier to reimburse only procedure codes with that modifier
• When left blank, only procedure codes without modifiers are reimbursed

Note: When using modifiers, the Procedure Code Reimbursement tool is recommended.

Percentage applied to the reimbursement

Dollar value applied to the selected table; when Override table values with list is selected, the values in this column override the values in the selected table

When selected, overrides the table’s base amount(s) with the value(s) listed in the Override column

Note: It is useful for ASC groupers to use one table across multiple contracts.

When selected, overrides the table’s base amount with the charged amount for each code

For facilities (Pennsylvania Medicaid only) that bill with TOS (type of service) codes

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

When selected, applies the Zero amount multiplier to codes that are not found in the table

For claims with revenue codes. For claims with revenue codes and procedure codes on the same line, use REV and PROC

For claims that include the revenue code and procedure code on the same line

• Choose the revenue code table from the drop-down list at the right of the option
• Choose the procedure code table from the Procedure Table drop-down list near the bottom of the page
• Do not select this option in conjunction with any other code type option

Determines the order of reimbursement:

• Table Amt–reimburses the code with the highest reimbursement first
• Charges–reimburses the code with the highest charges first
• Do not sort by charged amount–reimburses codes in the order in which they appear on the claim

When selected, calculates reimbursement based on units associated with each code. When not selected, calculates reimbursement based on the day. For example, if a procedure is performed two or more times on the same date, and this check box is not selected, the procedure is only paid once.

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

• All–reimburses each code from each table
• First–reimburses in the order in which the tables are listed
• Minimum–reimburses the code with the lowest reimbursement amount
• Maximum–reimburses the code with the highest reimbursement amount