epm 5.6 encounter rate billing july2010 - munson … · encounter rate billing in nextgen® epm...

EPM Encounter Rate Billing

NEXTGEN Healthcare Information Systems, Inc. Implementation and Training © Copyright, 1994-2010 All Rights Reserved Confidential and Proprietary DO NOT COPY

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Encounter Rate Billing - Overview

eLearning Curriculum: CHC Setup for Billing and Reporting eLearning Course: CHC Encounter Rate Billing Setup

Community Health Centers (CHC), which includes Federally Qualified Health Centers (FQHC), Rural Health Centers (RHC) and Indian Health Centers (IHC), have special billing needs that are quite different from other practices. A CHC often bills patient encounters to Medicare and/or Medicaid as a single line item on the claim instead of billing for each individual service performed on the claim. For example, all encounters for all patients are billed on the claim at the same encounter rate of $183.16 regardless of the services performed.

Encounter Rate billing in NEXTGEN® EPM provides the ability to automatically adjust the charges on a patient encounter by use of a contract, coupled with the automatic insertion of an Encounter Rate Code and price to be billed on the claim. The balance on the encounter reflects the expected encounter rate reimbursement.

Encounter Rate Billing Considerations: 1. Claims are configurable 2. Easy to maintain 3. Works well with ERA 4. Total charges are inflated due to the insertion of the encounter rate code on each encounter 5. Reporting on adjustments, outstanding A/R, etc. can be challenging. NEXTGEN offers pre-

defined Crystal Reports available that can help with some of these reporting challenges. 6. Paper claims for payers that are secondary to the encounter rate payer do not reflect the

amount paid from primary on the secondary claim



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Encounter Rate Billing Set Up

File Maintenance: File Maintenance > System EPM Master Files > Enterprises > Preferences > General Tab Encounter rate billing must first be enabled for the enterprise. This will also allow an Encounter Rate Library to be attached to the appropriate payer(s) later in the setup.

Encounter Rate Billing: Select this check-box



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File Maintenance > System EPM Master Files > CPT4 Codes Encounter rate billing involves the insertion of an encounter rate code on each patient’s encounter. The encounter rate code must first be created as a CPT4 code. In the example below, 521 is the encounter rate code needed on claims.

Code: Enter the code as it should appear on claims Description: Enter the description as it should appear on claims Type of Service: Select Medical Care



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File Maintenance > System EPM Master Files > EPM > Revenue Codes Verify the appropriate Revenue Code exists that is needed on UB claims in Field Locator 42 for the encounter rate payer. The Revenue Code will be linked to the encounter rate SIM code in the SIM Library. NOTE: This table comes pre-installed with 3-digit codes. A leading zero is automatically inserted on electronic claims (e.g.: 0521). If a 4-digit code is also needed on paper claims, it should be created here.

Code: Enter the code as it should appear in UB claims Description: Enter the description as it should appear on UB claims Occurrence Code: Leave blank (UB claim Field Locators 31 – 34) Value Code: Leave blank (UB claim Field Locators 39 – 41)



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File Maintenance > System EPM Master Files > Transaction Codes

Create a unique Transaction Code that will be used in a Contract created specifically for the encounter rate payer. The contract will be setup to automatically adjust charges as they are entered. Having a unique transaction code will assist in including/excluding encounter rate adjustments on financial reports in EPM. If encounter rate billing is done for more than one payer, create a separate Transaction Code for each payer. For example:

Medicare Enc Rate Adjustment Medicaid Enc Rate Adjustment

Transaction Description: Enter Encounter Rate Adjustment Type: Select Adjustment Source: Select Third Party Sign Type: Select Negative (-) Allow Sign Over Ride: Select this check-box



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File Maintenance > Master Lists > Departments Create a unique Department that will be used in the SIM Library only for the Encounter Rate SIM code(s). Having a unique department for these codes will assist in including/excluding and/or sorting the encounter rate codes by department on financial reports in EPM. If encounter rate billing is done for more than one payer, create a separate Department for each payer’s encounter rate SIM code. For example:

Medicare Enc Rate Medicaid Enc Rate

Description: Enter a description as it should appear on reports Show in EPM: Select this check-box Show in EHR: Do not select this check-box

IMPORTANT NOTE: The following department names are the only valid spellings for the UDS module and the Crystal Report provided by NextGen for Encounter Rate:

Enc Rate Medicare Enc Rate Medicaid Enc Rate EAPC Enc Rate EPSDT Enc Rate



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File Maintenance > Libraries > Service Items Create a Service Item Code (SIM) that matches the encounter rate CPT4 code created above.

Place of Service: Select Office Component: Select Professional Department: Select the unique department created above Revenue Code: Select the appropriate revenue code Form: Select 1500 Non-Facility and Facility Price: Enter the encounter rate amount

NOTE: The price fields can be set to $0.00 if it is desired to use the amount/price defined within the Encounter Rate Library.

Self Pay Qualifying Encounter: Select this check-box Sliding Fee Qualifying Encounter: Select this check-box Qualifying Encounter for all payers: Select this check-box



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File Maintenance > Libraries > Contracts A Contract is needed for Encounter Rate billing. The contract will be setup to automatically adjust charges as they are entered on encounters with the encounter rate payer attached. By adjusting the charges during charge posting, the outstanding AR on the encounter will reflect the expected rate of reimbursement NOTE: A separate Encounter Rate Library will need to be setup to insert the encounter rate SIM code that is required on the claim for each encounter. The contract for the encounter rate payer is typically setup in one of the following ways:

1. Encounter Rate Contract with 100% Adjustment 2. Encounter Rate Contract with 80% Adjustment / 20% Co-Pay

Encounter Rate Contract with 100% Adjustment This contract setup will adjust off 100% of each charge as it is entered, leaving a balance of $0.00. The Encounter Rate SIM defined in the Encounter Rate Library would then be inserted onto the encounter during the billing process. This setup might be used for Medicaid encounter rate billing. Contract Library Maintenance > General Tab

Create Zero Dollar Claim: Select this check-box

NOTE: If not selected, encounters will go to history status after the charges have been adjusted to $0.00 and the encounter rate code will not be inserted during the billing process.



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Automatically adjust charges: Select this check-box Default Auto-Adj Transaction: Select the adjustment transaction code to be used

NOTE: This should be a unique code created specifically for encounter rate adjustments.

Contract Library Maintenance > Fee Schedule Tab

CPT4: Select a CPT4 code that is to be adjusted off Effective/Expiration Dates: Enter the appropriate date range for each CPT4 code Type: Select FFS Allowed: Enter $0.00

NOTE: The difference between the charge amount (SIM Library) and the allowed amount (Contract) will be the adjustment amount. An allowed amount of $0.00 ensures the entire charge amount will be adjusted off during charge posting.

Participating Reimbursed: Enter 0% / $0.00

NOTE: This above setup does not apply to the Encounter Rate CPT4 code or to any carve-out codes that should not be adjusted to a balance of $0.00.



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Charge Posting using the Encounter Rate Contract with 100% Adjustment



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Encounter Rate Contract with 80% Adjustment / 20% Co-Pay:

This contract setup will adjust off 80% of each charge as it is entered, leaving a balance of 20% to be billed to a secondary payer as co-insurance or to the patient as a co-pay. The Encounter Rate SIM defined in the Encounter Rate Library would then be inserted onto the encounter during the billing process. This setup might be used for Medicare encounter rate billing.

Contract Library Maintenance > General Tab

Create Zero Dollar Claim: Select this check-box Apply Co-Pay to al Line Items: Select this check-box

NOTE: This ensures that the 20% balance will move to the secondary insurance or patient for all charges entered. Otherwise, the 20% balance would move to secondary or patient on the first charge only.

Automatically adjust charges: Select this check-box Default Auto-Adj Transaction: Select the adjustment transaction code to be used

NOTE: This should be a unique code created specifically for encounter rate adjustments.



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Contract Library Maintenance > Fee Schedule Tab

CPT4: Select a CPT4 code that is to be adjusted off Effective/Expiration Dates: Enter the appropriate date range for each CPT4 code Type: Select FFS Allowed: Set Allowed to 20% of the charge amount from the Service Item

Library

NOTE: The difference between the charge amount (SIM Library) and the allowed amount (Contract) will be the adjustment amount. An allowed amount of 20% ensures 80% of the charge amount will be adjusted off during charge posting.

Participating Reimbursed: Enter 0% / $0.00 Co-Pay: Set Copay to 20% of the charge amount from the Service Item

Library NOTE: This above setup does not apply to the Encounter Rate CPT4 code(s) or to any carve-out codes that should not be adjusted to a balance of 20%. Example: If the charge amount in the Service Item Library is $100 and the allowed amount in the contract is $20, then $80 (80%) will be adjusted off during charge entry. The co-pay in the contract of $20 (20%) will be moved to secondary insurance or to patient (if no secondary).



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Payers Table > Practice Tab > Other Sub-Tab

Accept financial responsibility of primary copay amt: Select this check-box for all payers that may be secondary to the 80/20 encounter rate payer. If not selected, the 20% balance will skip the payer when it is secondary and move the balance directly to the patient.

Charge Posting using the Encounter Rate Contract with 80% Adjustment / 20% Co-Pay



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File Maintenance > Libraries > Encounter Rate Billing The Encounter Rate Library is used to configure the billing rules for payers that require a flat encounter rate on claims. For example, all encounters for all patients are billed on the claim at the same encounter rate of $183.16 regardless of the services performed. The Encounter Rate Library allows for multiple configurations of claims. It also inserts an encounter rate code for the expected reimbursement amount. Therefore, the appearance of the claim is very different from the actual charges entered. IMPORTANT NOTE: All settings made in this library will be reviewed with your NEXTGEN Claims Analyst prior to and/or during claims testing. The Encounter Rate Billing Library Maintenance window is divided into two sections:

Encounter Rate SIM section

Business Rules section (includes 5 tabs)



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Encounter Rate Billing Library Maintenance > Encounter Rate SIM Section:

Set Configuration Hierarchy: The SIM Configuration Hierarchy is set by clicking on the Yellow Folder icon in the Encounter Rate SIM section. The defined hierarchy will be used in determining which encounter rate SIM code to insert during the billing process. If needed, use the blue up/down arrows to change the default hierarchy for Diagnosis, CPT4, Location, Provider, Sex, and/or Age. For example, if Diagnosis has a higher position in the hierarchy than Location, then EPM will use the encounter rate SIM defined for a specific diagnosis for all locations rather than the encounter rate SIM that applies to all diagnoses for a specific location. NOTE: In most cases, the default hierarchy will not need to be changed. Click OK to save the defined default hierarchy.



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Encounter Rate SIM Maintenance:

Right-click in the Encounter Rate SIM section and select New from the menu. The Encounter Rate SIM Maintenance window displays.

Service Item #: Select the encounter rate SIM code Description: Defaults from the SIM Library Effective/Expiration Dates: Defaults from the SIM Library but can be changed if needed Amount: Defaults from the SIM Library but can be changed if needed. The

Amount should be equal to the expected reimbursement.

Copay Amount: Enter the co-pay amount that should be deducted from the encounter rate amount entered above and settled to patient responsibility, if applicable

Condition Code: Select a default Condition Code, if applicable

(UB claim Field Locators 18 – 28)



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The following Service Item Configurations are optional. They define additional criteria, if any, that is required in order for the selected Encounter Rate SIM code to insert onto encounters and claims.

Required ICD9s: Used of encounter rate SIM code/amount is based on primary diagnosis Required CPT4s: Used if encounter rate SIM code/amount is based on CPT4 Valid Primary Payers: Available only if COB below is set to either 2 or 3. Used if encounter rate

SIM code/amount is based on Primary Payer Valid Locations: Used if encounter rate SIM code/amount differs by location Valid Providers: Used if encounter rate SIM code/amount differs by provider COB: Set to 1, 2, 3 or blank. Leaving COB blank indicates the encounter rate

SIM code should be used for primary, secondary and tertiary payers. If one row has a specific COB defined, then all other rows should have a COB. The hierarchy will always select rows with a specific COB over rows with a blank COB.

Sex: Used if encounter rate SIM code/amount is based on Sex Age: Used if encounter rate SIM code/amount is based on Age



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Example 1: Same Encounter Rate SIM Code for Primary and Secondary Claims with Different Amounts for Each



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Example 2: Different Encounter Rate SIM Codes for Primary and Secondary Claims with Different Amounts for Each



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Example 3: Different Encounter Rate SIM Codes for Primary, Secondary, Dental and Vision Claims with Different Amounts for Each

NOTE: Dental and Vision rows are configured by Location or by CPT4 code.



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Encounter Rate Billing Library Maintenance > Business Rules Section: This section is divided into five tabs:

1. General 2. Primary Payer Encounter Rate 3. Secondary Payer Encounter Rate 4. Tertiary Payer Encounter Rate 5. Claims

Encounter Rate Billing Library Maintenance > General Tab: Settings on this tab apply regardless of whether the encounter rate payer is primary, secondary, or tertiary on the encounter.

Suggested Settings: Encounter Rate Exempt: This applies when one or more of the charges on the encounter are flagged as Encounter Rate Exempt in the SIM Library.

Disqualify patient encounter from ER billing if = All SIMs are ER exempt Suppress claim for disqualified patient encounter = Unchecked



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Multiple Patient Encounters per day: This applies when multiple encounters exist for a patient on the same date of service.

The decision will be made by = Manual selection

Alternate Payer: This applies when the payer is setup with an Alternate Payer for split billing. (e.g.: Medicare A/Medicare B)

Do not insert ER SIM for alternate payer claims = Checked

Encounter Rate Billing Library Maintenance > Primary Encounter Rate Tab: Settings on this tab apply when the encounter rate payer is the primary insurance on the encounter.

Suggested Settings:

Suppress Claim Creation: This applies when multiple encounters exist for a patient on the same date of service.

Suppress claim for multiple same-day encounters (Multi-Yes only) = Checked

Encounter Rate Calculation: This applies if 20% of the original charges amounts should be added to encounter rate SIM code amount.

Add 20% of original charge line items to encounter rate amount = Unchecked



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Encounter Rate Billing Library Maintenance > Secondary and Tertiary Tabs: Settings on this tab apply when the encounter rate payer is the secondary or tertiary insurance on the encounter.

Suggested Settings:

Secondary/Tertiary Calculations when Medicare is the primary payer: This applies to secondary payers when Medicare is primary.

Encounter rate amount is equal to the = Encounter Rate Do not insert ER SIM if the ER amount is less than primary paid = Unchecked Do not insert ER SIM if the ER amount is equal to primary paid = Unchecked

Secondary/Tertiary Calculations when Non-Medicare is the primary payer: This applies to secondary payers when a payer other than Medicare is primary.

Encounter rate amount is equal to the = Encounter Rate Do not insert ER SIM if the ER amount is less than primary paid = Unchecked Do not insert ER SIM if the ER amount is equal to primary paid = Unchecked



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Suppress Claim Creation: This applies when multiple encounters exist for a patient on the same date of service.

Suppress claim for multiple same-day encounters (Multi-Yes only) = Checked Suppress zero dollar claims = Unchecked

Auto Adjustments: This controls automatic adjustments for secondary encounter rate payers.

Adjust remaining balance of charges for ER billed encounter

= Only adjust line item if ER SIM is inserted Adjust charges for non ER billed encounters = Checked Adjustment transaction code

= Unique code previously created and used in the Encounter Rate contract

ER SIM Insertion: Select this option to ignore the encounter rate billing functionality that verifies all line items on the encounter have payments from a previous payer. This option enables the insertion of the encounter rate SIM code even though the previous payer has not paid yet. Example: Wrap encounter rate payer.

Allow ER SIM to insert without previous payments = Unchecked



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Encounter Rate Billing Library Maintenance > Claims Tab: The previous tabs establish rules for how Encounter Rate Billing interacts with charge posting. The Claims tab allows for the configuration of claims, independent form what happens during charge posting.

Suggested Settings:

Primary / Secondary /Tertiary Electronic Claims: Allows for the selection of a specific Value Code needed on UB claims for the encounter rate payer in Field Locator 39. (NOTE: This was developed specifically for NY Medicaid)

Encounter rate value code = Unchecked (NY Medicaid may require a specific entry)

Primary / Secondary / Tertiary Claim Details: Controls how the charge lines will appear on claims for the encounter rate payer. Secondary and Tertiary Claim Details usually require the same setting as for primary. In the event that the secondary/tertiary payer does want a different claim configuration, it can be easily done with a different setting.

Display these line items on the claims = Set based on payer requirements

NOTE: Medicare (encounter rate billing) = Only ER SIM with sum of charge line items

Medicare (roll-up billing) = Only Rev Code with sum of charge line items Medicaid varies from state to state. The two most common settings are

Only ER SIM with sum of charge line items

Original charge line items & ER SIM with 0 amt. Include copay ER amount = Set based on payer requirements



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Ignore Claim Breaks Ensures that all charge lines get billed

Set all unbilled charge lines to Billed status = Unchecked



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File Maintenance > System EPM Master Files > Payers Both the Encounter Rate Library and the Encounter Rate Contract (including participating providers) must be attached to the appropriate payer(s) on the Practice tab > Libraries sub-tab. Attaching the Contract ensures that the charges are adjusted off during charge posting. Attaching the Encounter Rate Library ensures that the encounter rate SIM code is inserted onto the encounter during the billing process and that the claim is configured correctly for the encounter rate payer.

Encounter Rate Library: Select the Encounter Rate Library created for the payer Managed Care Contract: Select the Contract created for the payer Participating Providers: Select all providers for which the Contract applies



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Encounter Rate Billing Examples

Medicare:

Two charges are entered on the encounter, 99213 and 81002

Both CPT4 codes are defined in a Medicare contract to adjust off 80% of the charge amount with the remaining 20% to go to secondary or patient responsibility

An Encounter Rate Library is defined for Medicare to insert a 521 SIM code onto the encounter during the billing process

When the encounter is billed, a UB claim is created for Medicare with a single line item for the 521 encounter rate SIM code

The Total Charges on the claim equals the total of the original charges entered on the encounter ($110.00), not the encounter rate ($134.76). This claim configuration was defined in the Encounter Rate Library.



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Medicaid:

Two charges are entered on the encounter, 99213 and 81002

Both CPT4 codes are defined in a Medi-Cal contract to adjust off 100% of the charge amount

An Encounter Rate Library is defined for Medi-Cal to insert a 01 SIM code onto the encounter during the billing process

When the encounter is billed, a UB claim is created for Medi-Cal with a single line item for the 01 encounter rate SIM code

The Total Charges on the claim equals the encounter rate ($124.32), not the total of the original charges entered on the encounter ($110.00). This claim configuration was defined in the Encounter Rate Library.

epm 5.6 encounter rate billing july2010 - munson … · encounter rate billing in nextgen® epm...

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