To use the Medical Calculator to calculate reimbursements for Medical Services, follow these instructions.
Step 1. Select ‘Medical’
On the Calculator page, Medical is automatically selected.
Step 2. Enter ‘DOS’
An accurate reimbursement amount requires the Date of Service. Reimbursement amounts are calculated using the fee schedule(s) in effect on the date the services were rendered. The Calculator stores historical reimbursement data for dates of service from 2/15/2007 to present.
Step 3. Enter ‘Place of Service Zip Code’
The fee schedule is locality based.
Step 4. Select ‘Place of Service Type Code’
See CMS descriptions for Place of Service Types here.
Step 5. Enter ‘Procedure Code’
HCPCS / CPT Codes that describe services rendered.
Step 6. Optional: Enter ‘Modifiers’
Enter applicable Modifiers for the Procedure Code. Some Modifiers affect reimbursement calculations (referred to as ‘fee-affecting’ modifiers).
Step 7. Enter ‘Units’
Enter the number of Units to represent the quantity of the Procedure Code. Depending on the Procedure Code, a Unit might represent any of the following: number of report pages, a block of time, number of pills, etc.
Step 8. Optional: Enter ‘Payment Total’
Enter the reimbursement amount allowed by the claims administrator as reported on an explanation of review (EOR). This optional field defaults to $0. The Payment Total amount is used to calculate the Expected %.
Step 9. Optional: Repeat steps 5-8 for additional Procedure Codes
For physician dispensed pharmaceuticals use Procedure Code 99070 and enter the 11-digit NDC number.
Step 10. Click ‘Calculate’
Click the Trashcan icon to delete a Procedure Code prior to calculation.
Step 11. View the calculations
For more information on calculations see the Help Article: New York Calculator Results Explained.
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