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Assigning Fees to CPT Codes

Last Updated: Sep 19, 2014 11:36AM EST
Let's say your regular rate for 90806 is $120.00, but you have a negotiated rate of $80.00 for the insurance company of a particular client: $20.00 to be paid by the client as a copay, and $60.00 to be paid by insurance.. Even so, you would put (or keep) keep the 120.00 in the "Fee" blank when charting on the client. If the client paid the $20.00 at the time of the session, put 20.00 in the "Paid" blank. (If the client forgot their checkbook and paid nothing, put 0 in that blank.) So, it is really quite straightforward: just put in the blanks exactly what it is asking for--no thinking required!

When the EOB arrives with the check, you'll see an amount paid for the session, and an adjustment amount. The adjustment amount is called different things by different insurance companies: some call it "discount" for example. On the posting screen, locate the date of service for which you are receiving the check. Enter the amount paid by the insurance company in the "Ins. Payment" blank (60.00 in this example). Next, enter the adjustment amount in the "Adjust" blank as a positive number (40.00 in this example). Don't calculate what it SHOULD be, enter what is actually shown on the EOB. Click the button at the far right of that line to enter the information into the system.

If the insurance company is playing fair, all this should result in a zero balance for that line item, and the line will turn a nice serene blue. If they underpaid or overpaid, the line will turn red, a signal that a phone call may be in order. That item will also be placed on the "red list" (which you access by clicking "More..." and then "Bad Claims")--a list of all claims like this one that have problems, sorted in insurance company order so that you can deal with all of them in one phone call.
What if you are seeing a "sliding scale" client who had no insurance coverage? The easiest way is to adjust the fee appropriately while charting. If you are only charging a sliding scale client $60.00 for a 90806, replace the "Fee" with 60.00 (and hopefully they will pay the $60.00 fee at the time of the session, so you will enter 60.00 in the "Paid" blank as well. Alternatively, you could put 120.00 in the fee blank, and put in an adjustment of 60.00 on the posting screen, but this takes more steps. You would only go to that trouble if you are keeping careful records of the total discounts you are giving, both to insurance companies via negotiated rates, and to sliding scale clients via discounts.

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