FEE SCHEDULE is a schedule or list of fees to be paid or benefits that will be received under listed professional procedures or benefits. It defines rates for each CPT/HCPC codes. ‘U&C’ type (Usual and Customary type) is ‘default’ Fee Schedule Type and which is provided by AMA (US government).  This comprehensive listing of fee maximums is used to reimburse a physician and/or other providers on a fee-for-service basis.  Fee Schedules are prepared for physicians, ambulance services, clinical laboratory services, and durable medical equipment, prosthetics, orthotics, and supplies. Periodically, Fee Schedule is revised by AMA and user can either contact Bizmatics Tech Support or Use ‘Import’ feature on Fee Schedule to import. Payment from the Insurance Company depends on its contracted schedule and is independent of what is Billed, unless Billed amount is lower.

Type/Category:  It displays a list of defined Fee Schedule names, defined in the Group Master with type B6. Various fee schedules types like ‘U&C’, Medicaid’ can be defined. Select a Fee Schedule Type from the drop down list which displays existing Fee Schedule Types in system.

Schedule Name:  Assign meaningful Fee Schedule which might relate to the significance for which it was prepared.

From and Upto Date: Define a From and Upto Date. Normally the fee schedule changes once every year. However this is not a restriction. User can define fee schedules for any / multiple date ranges. When a claim is made (Or Recalc), it selects a fee schedule where the Claim Date of Service (Visit Date) falls within the fee schedules date range. It is in mm-dd-yyyy format

Note: ‘From’ date can be entered up to five years back from today’s date.
Note: Upto’ date can be entered up to three years ahead from today’s date.

Special: Checkbox ‘Special’ provides special status to the selected Fee Schedule. This check box is used to define a special schedule for say very poor patients, or say patients not having any Insurance. Normally selecting subsequent fields is not recommended.

Note:  For ‘Special’ Schedules, user must set ‘From’ and ‘Upto’ Dates, while it is ‘Not’ mandatory for Normal Billing Schedules.

Allowed: When radio button 'Allowed' is checked then 'Allowed' Fee Schedule is computed according to percentage defined on Fee Schedule for selected insurance. 'Allowed' Fee Schedule is calculated as soon as claim is processed.

BU Code:  It displays list of Business Unit Codes entered in PrognoCIS system. By default, option ‘All’ is selected. When ‘All’ is selected, specific Fee Schedule will be applicable for all business locations in claims or remittances otherwise would be applicable to specific Business Unit Location selected in drop down. Feature to select ‘All’ or ‘specific’ Business Unit Code helps because a clinic can have multiple Business Units, it is likely that each follows a different fee schedule.

Billing and Allowed Schedule Radio Button: By default, for Billing Fee schedule radio button ‘Billing’ will be checked. Radio button ‘Allowed’ Fee schedule will be used to define what should be the allowed amount expected from Insurance.

Loc Code:  It displays list of Location Codes listed out in PrognoCIS system. By default, option ‘All’ is selected. When ‘All’ is selected, specific Fee Schedule will be applicable for any location in claims or remittances otherwise would be applicable to specific Location selected in drop down.

Insurance Name:  Create specific Fee Schedule for specific Insurance Company when it may demand to be ‘Billed’ by a specific schedule. Using search pop up list using binocular icon, choose Insurance Name. By default, option ‘All’ is displayed. When ‘All’ is selected, specific Fee Schedule will be applicable for any Insurance Company in claims or remittances otherwise would be applicable to specific Insurance Company as selected using binocular. Use hyperlinked ‘clear’ to clear the selection.

Provider:  Certain senior providers may have a contract with the Insurance to get paid a higher rate than their juniors. They would as such like to charge a differential rate to Insurance / Patient. In such a case define the Fee Schedule for a specific Rendering provider. Use the Binocular to select the Insurance, and the clear hyperlink to clear the selection.

Out of Network: The clinic does not have a contract with all Insurance companies. If an Insurance company is defined as Outside of Network (Settings à Configuration à Insurance Master àOutside of Network Check Box), there can be a common different Fee Schedule. Mark the checkbox ‘Out of Network’ to differentiate that specific Fee Schedule is applicable ‘Out Of Network’ Insurance Company.

Code Type: Select one of the applicable code types from drop down list are as follows:

• CPT Codes
• HCPC Codes
• Ub04 Revenue Codes
• Special Charge Codes (e.g. for No Show, Check Returned)
• Item Codes
• SuperBill CPT
• SuperBill HCPC
• Pref CPT
• Pref HCPC

From Code: Key in code here. The program always display 100 records at a time. User can enter the code in this edit control slowly. Note that it auto completes. Alternately user can click on the search button to select the required starting code. On selecting a new starting code, the earlier entered data is automatically saved. Display of CPT/HCPC codes on Fee Schedule Type is governed by property ‘fee.schedule.maxrow’.

Add Codes: Periodically, new CPT/ HCPC codes are made available from AMA and get automatically added to the database. Users can add codes explicitly like some Special Codes / Items. These are codes which were ‘Not’ part of the existing Fee Schedule need to be added. Click button ‘New Codes’, check for all codes which are missing and add them to the fee schedule.

Modifiers: Prognocis Assessment has a provision of assigning one or more Modifiers to each CPT Code. These codes influence the variance in charges to be considered. Group Master Type CM has a provision to define the modifier codes, along with applicable percentage. To explore Modifiers in detail refer to the link at bottom.

Add Modifier:Considers the comma separated list of modifiers defined in the property Billing > fee.fixrate.modifiers and creates separate rows for Current Row CPT Code and each of these modifiers, so that user can define a flat rate for them. This way there can be a separate rate for say CPT 10560 with out modifiers = $1000, another rate for 10560 with modifier TC = $1100 and another rate for 10560 with modifier 26 = $1200.

Button ‘Add Mod’ allows user can associate multiple modifiers to current charge code selected on a fee schedule. When button ‘Add Mod’ is clicked, a pop up ‘Assign Modifier’ is displayed. User can select multiple modifiers from the list displayed on pop up.  The selected modifier will get associated to currently selected charge code on the Fee schedule. When button ‘Ok’ is selected, various combinations with entry of charge code along with selected modifiers are added to the Fee Schedule. If a combination already existed then that combination will not be disturbed. Now user can set fix rate for Fee for that combination and will be pulled in claim or remittance when a specific combination of charge code and modifier used in claim or remittance according to Fee Schedule selected.

Note: Default modifier to a charge code can be added on CPT/HCPC Master. Using search binocular, select and add default modifier to a charge code on CPT/HCPC master. Whenever such codes are used in Fee Schedule, default modifier is automatically populated in Fee Schedule and user can define fee rate for the same.

New Codes: A button ‘New Codes’ has been added before button ‘Add Mod’. This button ensures that new CPT/HCPC codes which have been added to the master will be available in the current Fee Schedule. This is basically helps to achieve synchronization between Master and Current Fee Schedule. If any rates or codes are missing from Fee Schedule then entered new rates and codes will be saved using button ‘New Codes’. This feature now adds to the flexibility to automatically save and update Fee Schedule with new rates and codes up on save.

Delete Mod: Button ‘Delete Mod’:  If the Current row did not have any modifier, then all rows with combination of Charge row and modifiers will be deleted. If the current row had a modifier, only then the current row will be deleted.

save:  It saves the changes done on Fee Schedule. Whenever user tabs out of the field on Fee Schedule after making changes, button ‘save’ is enabled otherwise not.

delete:  Button ‘delete’ physically deletes entire Fee Schedule.

calc:  Typically the schedule Published by Medicare for the region. It is considered as a base schedule and all other schedules are derived from it. Button ‘calc’ helps the user to compute the current schedule in terms of a percentage of reference schedules. Typically U&C schedule = 200% of Medicare. Button ‘calc’ provides feature to calculate fee for all charge code types type (‘CPT’/’HCPC’/’UB04 Revenue Charges’/’Special Charges’/’ITEM’) at once using option ‘All’ for ‘For Code Type’ dropdown list. User can also individually calculate fee for each code type.

Export / Import:  PrognoCIS supports ‘Export’ and ‘Import’ of Fee Schedule in CSV format using button ‘Export’ and ‘Import’ on Fee Schedule screen. Click button ‘Export’ to export Fee Schedule using ‘download’ pop up which is displayed on click. It is exported to desired location after choosing path on ‘save’ pop up. By default, ‘FeeSchedule.csv’ is created.
To import Fee Schedule, click button ‘Import’. ‘Upload’ pop up is displayed and browse the Fee Schedule CSV format file to import. After browsing the required CSV to import, attach the file to (upload) import to ‘blsummarylayout’ folder.