Price Principal Procedures
The essence of marking a procedure as principal for pricing purposes is that a price principal procedure must match if the evaluation has some restriction on procedures, procedure groups and/or procedure conditions. The evaluation can be for:
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Provider Pricing Clause
Procedure groups (3x) Procedure conditions (3x)
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Charged Amount
Procedure groups (3x) Procedure conditions (3x)
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Pricing Rule
Procedure groups (3x) Procedure conditions (3x)
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Fee Schedule Line
Procedures (3x) Procedure groups (3x)
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Combination Adjustment Rule
Procedure groups for secondary procedure (3x) Procedure conditions for secondary procedure (3x)
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Inclusion Rule
Procedure groups for not included procedure groups (3x) Procedure conditions for not included procedure conditions (3x)
Below a number of scenarios will illustrate this principle.
Scenario 1 No Principal Procedure
Procedure1 is configured for Revenue codes and procedure2 is configured for CPT codes.
Consider the following Provider Pricing Clauses and note that the sequence number of the procedure group does not correlate to the sequence number of the procedure. When the procedure group/condition usage is set to In there is a match if at least one of the three claim line procedures is in the specified procedure group/condition at the price Input date (this check is performed for every specified group and condition). To emphasize this point, the first procedure group in the example refers to CPT codes which is configured as procedure2.
Note also that procedure group could be just as well procedure condition, in any possible mix.
| PPC ID | Procedure Group 1 | Procedure Group 2 | Procedure Group 3 | Organization Provider | … |
|---|---|---|---|---|---|
1 |
(In) CPT 99xxx |
||||
2 |
(In) CPT 99xxx |
(In) Rev 028x |
|||
3 |
(In) Rev 028x |
||||
4 |
(In) CPT 99xxx |
(In) Rev 029x |
If this configuration is applied to the following claim line
| Line | REV | CPT | Provider | … |
|---|---|---|---|---|
1 |
0280 |
99201 |
then PPC 1, PPC 2 and PPC 3 evaluate to true and PPC 4 to false.
Scenario 2 Principal Procedure 1
Procedure1 is configured for Revenue codes and procedure2 is configured for CPT codes.
Consider the following Provider Pricing Clauses.
| PPC ID | Procedure Group 1 | Procedure Group 2 | Procedure Group 3 | Organization Provider | … |
|---|---|---|---|---|---|
1 |
(In) CPT 99xxx |
||||
2 |
(In) CPT 99xxx |
(In) Rev 028x |
|||
3 |
(In) Rev 028x |
||||
4 |
(In) CPT 99xxx |
(In) Rev 029x |
If this configuration is applied to the following claim line
| Line | REV | CPT | Provider | … |
|---|---|---|---|---|
1 |
0280 (Principal) |
99201 |
then PPC 2 and PPC 3 evaluate to true and PPC1 and PPC 4 to false. Because PPC 1 does not have a restriction on the price principal procedure REV code it is not chosen.
Scenario 3 Principal Procedure 2
Procedure1 is configured for Revenue codes and procedure2 is configured for CPT codes.
Consider the following Provider Pricing Clauses.
| PPC ID | Procedure Group 1 | Procedure Group 2 | Procedure Group 3 | Organization Provider | … |
|---|---|---|---|---|---|
1 |
(In) CPT 99xxx |
||||
2 |
(In) CPT 99xxx |
(In) Rev 028x |
|||
3 |
(In) Rev 028x |
||||
4 |
(In) CPT 99xxx |
(In) Rev 029x |
If this configuration is applied to the following claim line
| Line | REV | CPT | Provider | … |
|---|---|---|---|---|
1 |
0280 |
99201 (Principal) |
then PPC 1 and PPC 2 evaluate to true and PPC3 and PPC 4 to false. Because PPC 3 does not have a restriction on the price principal procedure CPT code it is not chosen.
Scenario 4 Principal Procedure 1 and Principal Procedure 2
Procedure1 is configured for Revenue codes and procedure2 is configured for CPT codes.
Consider the following Provider Pricing Clauses.
| PPC ID | Procedure Group 1 | Procedure Group 2 | Procedure Group 3 | Organization Provider | … |
|---|---|---|---|---|---|
1 |
(In) CPT 99xxx |
||||
2 |
(In) CPT 99xxx |
(In) Rev 028x |
|||
3 |
(In) Rev 028x |
||||
4 |
(In) CPT 99xxx |
(In) Rev 029x |
If this configuration is applied to the following claim line
| Line | REV | CPT | Provider | … |
|---|---|---|---|---|
1 |
0280 (Principal) |
99201 (Principal) |
then PPC 2 evaluates to true and PPC1, PPC 3 and PPC 4 to false. Because PPC 1 does not have a restriction on the price principal procedure REV code and PPC 3 does not have a restriction on the price principal procedure CPT code they are not chosen.
Similarly, if all three procedures would be marked as principal - an unlikely scenario - then only PPCs are chosen where all three procedures match one of procedure groups and/or procedure conditions (or the PPC does not have any restrictions on procedures, see scenario 5).
Scenario 5 Principal Procedure without Restriction on Procedure
Procedure1 is configured for Revenue codes and procedure2 is configured for CPT codes.
Consider the following Provider Pricing Clauses.
| PPC ID | Procedure Group 1 | Procedure Group 2 | Procedure Group 3 | Organization Provider | … |
|---|---|---|---|---|---|
1 |
(In) CPT 99xxx |
||||
2 |
(In) CPT 99xxx |
(In) Rev 028x |
|||
3 |
(In) Rev 028x |
||||
4 |
(In) CPT 99xxx |
(In) Rev 029x |
|||
5 |
Boston General |
If this configuration is applied to the following claim line
| Line | REV | CPT | Provider | … |
|---|---|---|---|---|
1 |
0280 (Principal) |
99201 |
Boston General |
then PPC 2, PPC 3 and PPC 5 evaluate to true and PPC1 and PPC 4 to false. Because PPC 5 does not have any restriction on procedure groups or procedure conditions at all, it just matches on the other fields; whether one or more of the procedures are marked as principal is then irrelevant.
Scenario 6 Principal Procedure in Inclusion Rule
Procedure1 is configured for Revenue codes and procedure2 is configured for CPT codes.
Consider the following (part of) Inclusion Rules.
| Rule | Not Included Procedure Group 1 | Not Included Procedure Group 2 | … |
|---|---|---|---|
1 |
(In) CPT 99xxx |
||
2 |
(In) Rev 028x |
If this configuration is applied to the following claim lines (assuming that all other conditions are met for the claim lines)
| Line | REV | CPT | Provider | … |
|---|---|---|---|---|
1 |
0280 |
|||
2 |
99201 |
|||
3 |
0280 |
99201 |
||
4 |
0280 (Principal) |
99201 |
||
5 |
0280 |
99201 (Principal) |
||
6 |
0280 (Principal) |
99201 (Principal) |
then
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for rule 1 claim lines 2, 3 and 5 will be excluded
-
for rule 2 claim lines 1, 3 and 4 will be excluded