Administration: Fee Schedule

Types of Fee Schedules

• Charge fee schedules: Autofills the fee for the CPT code.
• Expected fee schedules: Autofills the allowed amount, which is used in underpayment reporting. 

Types of Fees Included from the Medicare Fee Schedule

NextGen® Office loads the CMS PFS National Payment File; typically only the "A" file, released by January 1 of the calendar year. We do not import every quarterly update.

• Common codes not included in this file are lab codes and DME codes.
• We only load the Non-Facility Price.
• We recommend always charging above the allowable price to ensure the charge is above the allowable amount in the event of a quarterly fee schedule change.

To learn how to add fees to the fee schedule, see Add Fees.

RVU Defined

Relative value units (RVU) are a part of the resource-based relative value scale (RBRVS) and are used in the Medicare reimbursement formula for physician services. Each service in the fee schedule is scored based on the RBRVS to determine payment.

Providers receive reimbursements from Medicare for services based on claim submission using one or more CPT codes. Each CPT code has an RVU assigned to it, which when calculated with the GPCI (geographic adjustment) and conversion factor results in the compensation to the provider for a specific service.

Medicare Physician Fee Schedule Payment Rate Formula

Note: The decision to use RVUs and conversion factors to determine your charge fee schedule is a complex process and should be made by your billing staff. NextGen Office cannot provide the in-depth decision-making information that is required to make this determination.

For more information about how to use the Physician Fee Schedule lookup tool, refer to CMS's How to Use the Searchable Medicare Physician Fee Schedule (MPFS) (PDF) and Physician Fee Schedule Overview.

Navigate to Fee Schedule

1. On the Practice Management menu bar, click Admin.
2. Below Insurance and Billing, click Fee Schedule.

Create a Fee Schedule

1. Click New Fee Schedule. 

2. Enter the fee schedule's Title.
3. For the fee schedule Type, select Charge Amount or Expected Amount.
4. Select the Location to be associated with the fee schedule locality (based on Medicare).
5. To select Providers, select the All Providers option or the Selected Providers option. To select a provider, click to the select the provider and then click Add to move the provider to the right side.

6. For the Insurance Profile, select the All Profiles option or the Selected Profile(s) option. Make your selections and click Add to move them to the right side.
   • Payer Class: This list is generated from the payer class options when adding an insurance profile in the patient chart.
   • Payer Name: This list is generated from the users list of payers in Administration: Payer Maintenance.
   • Plan Name: This list is generated from the plan names created in Administration: Payer Plan Maintenance.
7. Click Next at the bottom of the page.

Fee Schedule Templates

Medicare, Total RVU, and Work RVU

1. Select a Template.
2. For the Medicare option, select the Year and Percent or enter a value.
3. For Total RVU or Work RVU options, select the Year and Conversion Factor.
4. For Procedure Codes, All Codes is the default option. If you choose the Selected Code(s) option, search for procedure codes and click Add to move them to the right side.
5. Click Save Fee Schedule.

Note: Only codes from the standard Medicare fee schedule are created. Lab and drug codes must be added using the Custom template.

Custom – Superbill as Template

There are three custom options available. CSV upload is the recommended option if a large number of codes need to be entered. Custom codes override the Medicare and RVU templates.

1. Select the Custom template option.
2. Click Enter Carve Outs & Modifiers.

3. Select a superbill.

4. Enter an Amount for the desired codes.
5. Click Save.

Custom – Manually Add Codes

1. Enter the procedure code or description and click Search. J and G codes must be entered with capitalized letters.
2. Select modifier(s) (optional).

3. Enter the Amount.
4. Click Save Fees. 
5. Continue adding codes and fees. When finished, click Save Fee Schedule. 

Custom – Upload CSV File

1. Click View sample file to download a template. Follow the instructions provided in the template.

2. Click Save Fee Schedule.

Add Fees

1. To edit an existing fee schedule, click Edit Fee Schedule  . 

2. Click Next at the bottom of the page.
3. Click Add More Fees.

4. Select the Custom template option.
5.  Click Enter Carve Outs & Modifiers.

6. Add fees using a superbill as a template, manually adding codes, or uploading a CSV file.