PrognoCIS Help: Fee Schedule

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Introduction: A 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/HCPCS code. The 'U&C' type (Usual and Customary type) is the default Fee Schedule Type, which is provided by the AMA (American Medical Association). 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, the Fee Schedule is revised by the AMA, and the user can either contact Bizmatics Tech Support or use the 'Import' feature on the Fee Schedule to import. Payment from the insurance company depends on its contracted schedule and is independent of what is billed, unless the billed amount is lower.

Field Description:

Add Button: Click this icon to add a new Fee Schedule record.

Search Button: Click this icon to invoke the 'Fee Schedule' Search List, which shows all active and existing Fee Schedule records stored in the system. The columns shown on this popup include Type, Name, From Date, Up to Date, Allow, and Spl. The 'Parent Name' column is shown in this Search List only when the property, show.copy.option.on.fs is set to On.

Properties: This button is exclusively visible to users with Read Access to the Properties Master screen. Access to this button is strategically granted to enhance user functionality. Clicking the Properties Button triggers a popup, presenting a list of properties from the Properties Master screen in PrognoCIS that cater to the Fee Schedule.

Type: It displays a list of defined Fee Schedule names, defined in the Group Master with Type B6. Various fee schedule types like 'U&C' and 'Medicaid' can be defined. Select a Fee Schedule Type from the dropdown list, which displays the existing Fee Schedule Types in the system. If the Type supports Employer Services, the 'Special' checkbox, 'BU Code' field, 'POS Code' field, 'Billing' radio button, and 'Allowed Schedule' radio button are disabled.

Schedule Name: Enter a name for the schedule.

Note: The criteria for the SelfPay Fee Schedule require the Fee Schedule Name to start with the 'Selfpay' keyword, and the 'Special' checkbox must be checked. The 'Selfpay' keyword is not case-sensitive.

Parent Info: When a Child Fee Schedule has been copied from a Parent Fee Schedule record, a 'Parent Info' hyperlink is shown next to the 'Schedule Name' field of the Child Fee Schedule. Click this hyperlink on a Child Fee Schedule record to invoke the 'Parent Fee Schedule' popup, which shows the Parent Fee Schedule Name from which the Child Fee Schedule was copied along with its Status.

Child Info: When a Child Fee Schedule has been copied from a Parent Fee Schedule record, a 'Child Info' hyperlink is shown next to the 'Schedule Name' field of the Parent Fee Schedule. Click this hyperlink on a Parent Fee Schedule record to invoke the 'Child Fee Schedules' popup, which shows the Child Fee Schedule Names associated with the Parent Fee Schedule along with their individual statuses.

From and Up to Date: Define a From and Up to Date. Users can define fee schedules for any or multiple date ranges. When a claim is created and the Recalc button is clicked, the system selects the Fee Schedule where the claim's Date of Service falls within the defined fee schedule's date range and populates it on the Claims screen. The date is in mm-dd-yyyy format.

Note:

The 'From' date can be entered up to five years back from today's date.
The 'Up to' date can be entered up to three years ahead of today's date.

Special: The 'Special' checkbox provides special status to the selected Fee Schedule. This checkbox is used to define a special schedule for, say, very poor patients, or patients who do not have any insurance. Normally, selecting subsequent fields is not recommended. For the SelfPay Fee Schedule, it is mandatory to select the 'Special' checkbox.

Note: For 'Special' schedules, the user must set 'From' and 'Up to' dates, while it is not mandatory for normal billing schedules.

Allowed: When the 'Allowed' radio button is selected, the 'Allowed' Fee Schedule is computed according to the percentage defined in the Fee Schedule for the selected insurance. The 'Allowed' Fee Schedule is calculated as soon as the claim is processed.

BU Code: It displays a list of Business Unit Code - Business Unit Name combinations entered in PrognoCIS. By default, the option 'ALL-ALL' is selected. When 'ALL-ALL' is selected, a specific Fee Schedule is applicable to all business locations in claims or remittances; otherwise, it is applicable to the specific Business Unit selected in the dropdown.

Pos Code: It displays a list of Place of Service Code - Place of Service Name combinations entered in PrognoCIS. By default, the option 'ALL-ALL' is selected. When 'ALL-ALL' is selected, a specific Fee Schedule is applicable to all places of service; otherwise, it is applicable to the specific Place of Service selected in the dropdown.

Billing and Allowed Schedule Radio Buttons: By default, for the Billing Fee Schedule, the 'Billing' radio button is selected. The 'Allowed' radio button is used to define the allowed amount expected from the insurance company.

Loc Code: It displays a list of Location Code - Location Name combinations listed in the PrognoCIS system. By default, the option 'ALL-ALL' is selected. When 'ALL-ALL' is selected, a specific Fee Schedule is applicable to any location in claims or remittances; otherwise, it is applicable to the specific Location selected in the dropdown.

Insurance Name: This field allows the user to create a specific Fee Schedule for a specific Insurance Company when it demands to be 'Billed' by a specific contract schedule. The Fee Schedule is then applicable only to that Insurance. Click the

Search binocular icon to select the Insurance, and click the 'Clear' hyperlink to clear the selection. By default, the option 'All' is displayed.

Provider: Certain senior providers may have a contract with the insurance company to be paid at a higher rate than their juniors. They would, as such, like to charge a differential rate to the Insurance or Patient. In such a case, define the Fee Schedule for a specific Rendering Provider. Click the

Search binocular icon to select the Provider from the list. A 'Clear' hyperlink is provided to clear the selection.

Out of Network: The clinic does not have contracts with all insurance companies. If an insurance company is defined as Outside of Network (Settings → Configuration → Insurance Master → Outside of Network checkbox), there can be a different, common Fee Schedule. Select the 'Out of Network' checkbox to specify that the Fee Schedule is applicable to an 'Out of Network' insurance company.

Employer: Click the

Search icon next to the 'Employer' field to invoke the 'Employer' Search List. This Search List shows only those employers whose Type is the same as that selected on the Fee Schedule. Select employers from the Search List to display them in the 'Employer' field, separated by commas. Click the

'Remove Employer' icon to invoke the 'Remove Employer' popup and remove any selected employers from the 'Employer' field. Click the 'Clear' link to remove all selected employers from the 'Employer' field at once.

Code Type: Select one of the applicable code types from the dropdown list:

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

The SuperBill CPT/HCPCS code types are provided. These act as a filter and display only the corresponding CPT/HCPCS codes that have rates assigned to them. Similarly, the Preferred CPT/HCPCS code types also act as a filter and display only the corresponding CPT/HCPCS codes that are Clinic Preferred or Doctor Preferred and their rates (whether assigned or not).

From Code: Key in the code here. The program always displays 100 records at a time. The user can enter the code in this field slowly; note that it auto-completes. Alternatively, the user can click the

Search binocular icon to select the required starting code. Upon selecting a new starting code, the previously entered data is automatically saved. The display of CPT/HCPCS codes on the Fee Schedule Type is governed by the property, fee.schedule.maxrow.

Add Codes: Periodically, new CPT/HCPCS codes are made available by the AMA and are automatically added to the database. Users can explicitly add codes, such as Special Codes or Items. These are codes that were not part of the existing Fee Schedule and need to be added. Click the 'New Codes' button, check for any missing codes, and add them to the Fee Schedule.

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

Add Mod Button: This option considers the comma-separated list of modifiers defined in the property, fee.fixrate.modifiers, and creates separate rows for the current row's CPT code and each of these modifiers so that the user can define a flat rate for them. This way, there can be a separate rate for, say, CPT 10560 without modifiers ($1,000), another rate for 10560 with modifier TC ($1,100), and another rate for 10560 with modifier 26 ($1,200).

The 'Add Mod' button allows the user to associate multiple modifiers with the current charge code selected on a Fee Schedule. When the 'Add Mod' button is clicked, an 'Assign Modifier' popup is displayed. The user can select multiple modifiers from the list displayed on the popup. The selected modifiers will be associated with the currently selected charge code on the Fee Schedule.

While adding a modifier using the 'Add Mod' button, the system enforces a mandatory rate entry. A mandatory indicator appears next to the Rate field when a modifier checkbox is selected. If a user attempts to save a modifier without defining a rate, a validation message is displayed, which reads: Please enter a valid Rate. It must be greater than zero. This ensures that no zero-dollar CPT/HCPCS codes are added when modifiers are applied, further supporting screen optimization and data integrity.

When the 'OK' button is selected, various combinations of charge codes, selected modifiers, and rate entries are added to the Fee Schedule. If a combination already exists, that combination will not be disturbed. The rate set for the fee of that combination is pulled into the claim or remittance when a specific combination of charge code and modifier is used in the claim or remittance, according to the selected Fee Schedule.

Note: A default modifier for a charge code can be added in the CPT/HCPCS Master. Using the Search binocular icon, select and add a default modifier to a charge code on the CPT/HCPCS Master. Whenever such codes are used in a Fee Schedule, the default modifier is automatically populated in the Fee Schedule, and the user can define the fee rate for it.

New Codes Button: This button ensures that new CPT/HCPCS codes that have been added to the master will be available in the current Fee Schedule. This basically helps to achieve synchronization between the Master and the current Fee Schedule. If any rates or codes are missing from the Fee Schedule, the entered new rates and codes will be saved using the 'New Codes' button. This feature adds the flexibility to automatically save and update the Fee Schedule with new rates and codes upon saving.

Delete Mod Button: If the current row does not have any modifier, then all rows with the combination of the charge row and modifiers will be deleted. If the current row has a modifier, only then the current row will be deleted.

Overridden: Turn On the newly added admin-level property, show.overridden.column.on.fs, to see an 'Overridden' column with checkboxes on the Child Fee Schedule record. By default, this property is Off. This column is displayed to the right of the 'Rates' column. If the rates of the codes are manipulated, the 'Overridden' checkbox is checked automatically.

Action Buttons:

Save: It saves the changes made to the Fee Schedule. Whenever the user tabs out of a field on the Fee Schedule after making changes, the 'Save' button is enabled; otherwise, it is disabled.

Save As button: Click the 'Save As' button to invoke the 'Save As Fee Schedule' popup, through which you can save a record with a different name and different 'From' and 'Up to' dates, but with the same data.

Delete Button: The 'Delete' button physically deletes the entire Fee Schedule.

Reset Button: Click the 'Reset' button to reset unsaved modifications in the Fee Schedule record.

History Button: Click the 'History' button to invoke the 'Fee Schedule History' popup. This popup displays the modification history of the Fee Schedule record, with details in the 'Modified By', 'Date', and 'Modified Notes' columns.

Calc Button: Typically, this is the schedule published by Medicare for the region. It is considered the base schedule, and all other schedules are derived from it. The 'Calc' button helps the user compute the current schedule in terms of a percentage of reference schedules. Typically, the 'U&C' schedule equals 200% of Medicare. The 'Calc' button provides a feature to calculate fees for all charge code types ('CPT', 'HCPCS', 'UB04 Revenue Charges', 'Special Charges', 'Item', 'DME') at once using the 'All' option in the 'For Code Type' dropdown list. The user can also individually calculate the fee for each code type.

Export Button: Click the 'Export' button to export the Fee Schedule using the 'Download' popup, which is displayed upon clicking. It is exported to the desired location after choosing the path in the 'Save' popup. By default, 'FeeSchedule.csv' is created.

Import Button: To import a Fee Schedule, click the 'Import' button. The 'Upload' popup is displayed; browse to select the Fee Schedule CSV format file to import. After browsing to find the required CSV file to import, attach and upload the file to the 'blsummarylayout' folder.

Compare Button: Click the 'Compare' button to invoke the 'Fee Schedule' Search List, which displays active as well as inactive Fee Schedule records. Users can select a maximum of 10 records from this Search List. After selecting the records, click the 'OK' button on the 'Fee Schedule' Search List to close it and invoke the 'Compare Fee Schedules' popup. The 'Compare Fee Schedules' popup consists of the Type, Code, and Name columns, and Schedule 1 $ to Schedule 10 $ columns depending on the number of Fee Schedule records selected.

Copy Button: This button is displayed on a Parent Fee Schedule record in PrognoCIS when the admin-level property, show.copy.option.on.fs is set to On. By default, this property is set to Off. Click the 'Copy' button to invoke the 'Copy Fee Schedule' popup, which can be used to create a Child Fee Schedule record by copying the contents of the Parent Fee Schedule record.

Note: Clinics that have multiple locations spread across states can create multiple locality-wise fee schedules. To enable the locality-wise fee schedule feature, turn the property billing.claim.wc.use.rvu.rates On. When this property is turned On, a new field, 'RVU Locality', is displayed on the Locations Master screen. Next to this field, a Search icon is displayed. Clicking the Search icon invokes the 'Locality' popup. The user needs to select the appropriate locality codes displayed in the popup. Based on the selected codes, a locality-wise fee schedule is created.