CPT Auto-Ordering with Expected Rates

Let's review how to use the CPT Auto-Ordering feature. You can watch a short video and read the article for more details.

Some payers reimburse based on a code's position on a claim. The codes with the highest unit value should appear first on the claim to capitalize on your contracted rates. Medicare, for example, will use a sliding scale reimbursement rule for subsequent service lines based on the multiple procedure payment reduction (MPPR) rate. If these service lines are not ordered correctly, based on the payer contract, then your clinic will leave money on the table.

Note: This feature is optional and can be turned on/off at any time. While active, you can still manually change the order of codes on a specific session. This feature affects all insurances. You cannot pick and choose.

Set-Up

1. Navigate to Admin > Defaults/Settings > Expected Rates.
2. Check the box next to Order CPT Codes from High Value to Low Value. 
3. Fill out any Expected Rate schedule desired. This can be done 2 ways.
   1. Manually - For more information, please see: Expected Rates Schedule
   2. Auto-Populate Default Schedule - Pressing this button will auto-fill the default schedule. For more information, see below. 

Auto-Populate Default Schedule

Using this button will auto-populate the Default Payer/Default Plan Expected Rates schedule for you. The system will only fill in fields that are currently blank. For example, if 97161 is blank, the system will find all instances of 97161 and calculate the average payment amount that has been posted.

Note: The system will also split each code by modifier when auto-populating the rates. For example, 97161, 97161.GP, and 97161.GP.KX could all appear and have different rates.

Before	After

I have multiple Expected Rate Schedules. Which one does the system use?

The system uses a hierarchy to determine the order of codes on a session from the most specific to least specific. If the system does not find an expected rate in the first schedule, it will search the second, and then the third. If no expected rate is found for a code, it will be treated as a 0.00 value.

1. Specific Payer/Specific Plan
2. Specific Payer/Default Plan
3. Default Payer/Default Plan 

My schedule used Fixed Rates, Per Unit, and Per Minute values. How is the order determined then?

The system converts all expected rates to a Per Unit value.

• Fixed Rate: $100 fixed = $100/unit
• Per Unit: $100 for 4 units = $25/unit
• Per Minute: Not convertable = $0/unit
• No Value: $0/unit

Can I see the Expected Rates on a session?

When you are on the Edit Session window, you can easily see the Expected Rate if there is only 1 service line. If there are multiple service lines, you can use the icon to see each line's Expected Rate.